- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.05 / $1,163.45 / $1,844.21
| Professional | | $972.05 | $1,163.45 | $1,844.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.38 / $1,424.20 / $2,311.61
| Professional | | $1,128.38 | $1,424.20 | $2,311.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.30 / $1,625.30 / $2,627.79
| Professional | | $1,149.30 | $1,625.30 | $2,627.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.34 / $1,697.04 / $9,976.00
| Professional | | $1,189.34 | $1,697.04 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.66 / $1,552.68 / $2,556.33
| Professional | | $1,134.66 | $1,552.68 | $2,556.33 |