- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.34 / $1,767.44 / $6,328.48
| Professional | | $1,121.34 | $1,767.44 | $6,328.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.60 / $1,766.95 / $2,495.00
| Professional | | $1,213.60 | $1,766.95 | $2,495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.67 / $662.04 / $1,064.23
| Professional | | $93.67 | $662.04 | $1,064.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.79 / $2,020.54 / $3,066.93
| Professional | | $1,497.79 | $2,020.54 | $3,066.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.18 / $1,264.69 / $2,024.19
| Professional | | $1,031.18 | $1,264.69 | $2,024.19 |