- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.07 / $1,298.57 / $2,575.03
| Professional | | $618.07 | $1,298.57 | $2,575.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.00 / $1,025.00 / $1,025.00
| Professional | | $1,025.00 | $1,025.00 | $1,025.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.02 / $981.10 / $1,527.03
| Professional | | $679.02 | $981.10 | $1,527.03 |
- 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
- $837.48 / $1,037.92 / $2,215.69
| Professional | | $837.48 | $1,037.92 | $2,215.69 |