- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.55 / $1,599.77 / $1,666.03
| Professional | | $823.55 | $1,599.77 | $1,666.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.00 / $1,360.00 / $1,360.00
| Professional | | $1,360.00 | $1,360.00 | $1,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.83 / $1,259.74 / $1,784.78
| Professional | | $868.83 | $1,259.74 | $1,784.78 |
- 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
- $695.93 / $1,034.72 / $1,524.85
| Professional | | $695.93 | $1,034.72 | $1,524.85 |