- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.06 / $1,072.06 / $1,283.10
| Professional | | $1,072.06 | $1,072.06 | $1,283.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.47 / $1,476.87 / $2,133.31
| Professional | | $1,233.47 | $1,476.87 | $2,133.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.98 / $1,584.81 / $2,452.71
| Professional | | $1,352.98 | $1,584.81 | $2,452.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.47 / $1,588.61 / $2,437.01
| Professional | | $1,233.47 | $1,588.61 | $2,437.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.06 / $1,072.06 / $1,283.10
| Professional | | $1,072.06 | $1,072.06 | $1,283.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.82 / $1,588.61 / $2,243.98
| Professional | | $1,128.82 | $1,588.61 | $2,243.98 |