- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.16 / $223.04 / $1,720.81
| Professional | | $76.16 | $223.04 | $1,720.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,282.00 / $1,282.00 / $1,282.00
| Professional | | $1,282.00 | $1,282.00 | $1,282.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.39 / $727.44 / $1,522.99
| Professional | | $94.39 | $727.44 | $1,522.99 |
- 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
- $657.75 / $966.98 / $1,501.05
| Professional | | $657.75 | $966.98 | $1,501.05 |