- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,412.54
| Professional | | $575.44 | $724.44 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,818.38
| Professional | | $1,023.29 | $1,023.29 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,479.11
| Professional | | $691.83 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $1,548.82
| Professional | | $562.34 | $758.58 | $1,548.82 |