- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,754.23
| Professional | | $912.01 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,398.83
| Professional | | $1,023.29 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $2,454.71
| Professional | | $1,174.90 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,884.03
| Professional | | $1,258.93 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $3,090.30
| Professional | | $1,023.29 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,344.23
| Professional | | $933.25 | $1,288.25 | $2,344.23 |