- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.35 / $1,153.41 / $2,739.55
| Professional | | $967.35 | $1,153.41 | $2,739.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.57 / $2,614.66 / $3,268.32
| Professional | | $2,008.57 | $2,614.66 | $3,268.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.68 / $2,494.92 / $9,976.00
| Professional | | $1,195.68 | $2,494.92 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.66 / $2,503.90 / $3,172.81
| Professional | | $1,848.66 | $2,503.90 | $3,172.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.63 / $1,971.72 / $2,247.98
| Professional | | $1,329.63 | $1,971.72 | $2,247.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.68 / $2,145.11 / $3,336.84
| Professional | | $1,195.68 | $2,145.11 | $3,336.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.10 / $2,728.60 / $2,728.60
| Professional | | $2,230.10 | $2,728.60 | $2,728.60 |