- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.27 / $6,175.77 / $6,175.77
| Professional | | $1,065.27 | $6,175.77 | $6,175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.78 / $1,013.87 / $1,515.51
| Professional | | $824.78 | $1,013.87 | $1,515.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.84 / $1,270.84 / $1,270.84
| Professional | | $1,270.84 | $1,270.84 | $1,270.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.87 / $984.01 / $1,505.70
| Professional | | $712.87 | $984.01 | $1,505.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.48 / $1,176.26 / $1,753.85
| Professional | | $876.48 | $1,176.26 | $1,753.85 |