- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.11 / $975.90 / $1,683.64
| Professional | | $498.11 | $975.90 | $1,683.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $60.00 / $1,786.42
| Professional | | $30.00 | $60.00 | $1,786.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.53 / $1,406.72 / $1,443.45
| Professional | | $1,117.53 | $1,406.72 | $1,443.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.12 / $771.56 / $1,162.24
| Professional | | $604.12 | $771.56 | $1,162.24 |