- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.09 / $1,514.65 / $1,770.39
| Professional | | $745.09 | $1,514.65 | $1,770.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.80 / $2,095.36 / $4,058.46
| Professional | | $1,476.80 | $2,095.36 | $4,058.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.90 / $2,313.34 / $4,351.75
| Professional | | $1,157.90 | $2,313.34 | $4,351.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.29 / $3,363.41 / $6,123.31
| Professional | | $1,758.29 | $3,363.41 | $6,123.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.29 / $3,191.83 / $3,755.20
| Professional | | $1,758.29 | $3,191.83 | $3,755.20 |