- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.65 / $1,770.53 / $6,175.75
| Professional | | $1,036.65 | $1,770.53 | $6,175.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.71 / $1,812.02 / $2,468.39
| Professional | | $1,259.71 | $1,812.02 | $2,468.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.95 / $795.60 / $1,270.76
| Professional | | $122.95 | $795.60 | $1,270.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.35 / $2,058.65 / $3,704.98
| Professional | | $1,464.35 | $2,058.65 | $3,704.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.16 / $1,524.80 / $2,370.03
| Professional | | $1,194.16 | $1,524.80 | $2,370.03 |