- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.08 / $1,013.08 / $1,017.26
| Professional | | $1,013.08 | $1,013.08 | $1,017.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.30 / $1,350.05 / $3,089.46
| Professional | | $1,145.30 | $1,350.05 | $3,089.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.20 / $1,425.01 / $1,922.49
| Professional | | $942.20 | $1,425.01 | $1,922.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.75 / $1,275.77 / $1,922.49
| Professional | | $889.75 | $1,275.77 | $1,922.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.13 / $1,207.49 / $3,510.25
| Professional | | $979.13 | $1,207.49 | $3,510.25 |