- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.84 / $1,223.98 / $1,464.65
| Professional | | $812.84 | $1,223.98 | $1,464.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.31 / $1,306.91 / $1,860.00
| Professional | | $1,017.31 | $1,306.91 | $1,860.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.96 / $1,505.82 / $2,113.16
| Professional | | $984.96 | $1,505.82 | $2,113.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.75 / $1,405.47 / $2,156.06
| Professional | | $1,214.75 | $1,405.47 | $2,156.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.84 / $1,424.50 / $1,464.65
| Professional | | $812.84 | $1,424.50 | $1,464.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.86 / $1,566.50 / $2,139.23
| Professional | | $1,061.86 | $1,566.50 | $2,139.23 |