- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.97 / $732.67 / $1,527.36
| Professional | | $570.97 | $732.67 | $1,527.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.00 / $1,027.00 / $1,027.00
| Professional | | $1,027.00 | $1,027.00 | $1,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.39 / $1,028.60 / $1,485.69
| Professional | | $628.39 | $1,028.60 | $1,485.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.24 / $853.60 / $1,669.05
| Professional | | $648.24 | $853.60 | $1,669.05 |