- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.20 / $242.20 / $1,015.19
| Professional | | $242.20 | $242.20 | $1,015.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.83 / $722.83 / $722.83
| Professional | | $722.83 | $722.83 | $722.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.00 / $367.00 / $367.00
| Professional | | $367.00 | $367.00 | $367.00 |
- 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
- $912.73 / $1,363.94 / $2,825.81
| Professional | | $912.73 | $1,363.94 | $2,825.81 |