- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.02 / $1,298.70 / $1,471.30
| Professional | | $1,042.02 | $1,298.70 | $1,471.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.33 / $1,347.86 / $2,074.83
| Professional | | $1,225.33 | $1,347.86 | $2,074.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.31 / $1,518.00 / $2,174.80
| Professional | | $1,201.31 | $1,518.00 | $2,174.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.30 / $1,453.16 / $2,229.21
| Professional | | $1,128.30 | $1,453.16 | $2,229.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.02 / $1,298.70 / $1,471.30
| Professional | | $1,042.02 | $1,298.70 | $1,471.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.84 / $1,600.80 / $2,013.42
| Professional | | $1,291.84 | $1,600.80 | $2,013.42 |