- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $2,951.21
| Professional | | $977.24 | $1,202.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $2,570.40
| Professional | | $1,122.02 | $1,659.59 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,398.83
| Professional | | $1,148.15 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $3,388.44
| Professional | | $1,513.56 | $1,819.70 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $4,073.80
| Professional | | $1,071.52 | $1,445.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $2,570.40
| Professional | | $954.99 | $1,513.56 | $2,570.40 |