- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.08 / $331.61 / $765.72
| Professional | | $265.08 | $331.61 | $765.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.00 / $1,147.00 / $1,147.00
| Professional | | $1,147.00 | $1,147.00 | $1,147.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.73 / $503.26 / $1,005.60
| Professional | | $264.73 | $503.26 | $1,005.60 |
- 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
- $305.01 / $610.02 / $1,099.83
| Professional | | $305.01 | $610.02 | $1,099.83 |