- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.71 / $1,000.88 / $1,203.31
| Professional | | $797.71 | $1,000.88 | $1,203.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.11 / $1,296.84 / $1,839.18
| Professional | | $1,002.11 | $1,296.84 | $1,839.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.54 / $1,443.98 / $2,060.62
| Professional | | $980.54 | $1,443.98 | $2,060.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.15 / $1,389.73 / $2,131.92
| Professional | | $1,201.15 | $1,389.73 | $2,131.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.71 / $1,096.71 / $1,203.31
| Professional | | $797.71 | $1,096.71 | $1,203.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.10 / $1,323.56 / $1,906.87
| Professional | | $925.10 | $1,323.56 | $1,906.87 |