- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $2,089.30
| Professional | | $1,230.27 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $2,884.03
| Professional | | $1,230.27 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,737.80 / $3,019.95
| Professional | | $912.01 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $3,467.37
| Professional | | $1,513.56 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,715.35
| Professional | | $1,230.27 | $1,862.09 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $2,884.03
| Professional | | $1,122.02 | $1,737.80 | $2,884.03 |