- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $275.42 / $1,230.27
| Professional | | $79.43 | $275.42 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $676.08 / $1,380.38
| Professional | | $87.10 | $676.08 | $1,380.38 |
- 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
- $79.43 / $616.60 / $1,318.26
| Professional | | $79.43 | $616.60 | $1,318.26 |