- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.61 / $1,084.06 / $1,403.19
| Professional | | $973.61 | $1,084.06 | $1,403.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.36 / $1,550.72 / $2,169.34
| Professional | | $1,375.36 | $1,550.72 | $2,169.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.14 / $1,860.13 / $3,102.71
| Professional | | $1,154.14 | $1,860.13 | $3,102.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.16 / $1,918.56 / $3,371.66
| Professional | | $1,125.16 | $1,918.56 | $3,371.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $2,349.57 / $5,708.18
| Professional | | $1,188.07 | $2,349.57 | $5,708.18 |