- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.68 / $1,749.31 / $6,808.46
| Professional | | $1,151.68 | $1,749.31 | $6,808.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.31 / $2,048.67 / $2,913.93
| Professional | | $1,429.31 | $2,048.67 | $2,913.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.95 / $923.18 / $1,459.08
| Professional | | $122.95 | $923.18 | $1,459.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.60 / $2,352.29 / $4,272.47
| Professional | | $1,602.60 | $2,352.29 | $4,272.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.31 / $1,707.09 / $2,701.61
| Professional | | $1,363.31 | $1,707.09 | $2,701.61 |