- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.08 / $1,043.08 / $1,056.03
| Professional | | $1,043.08 | $1,043.08 | $1,056.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.67 / $1,761.89 / $3,215.33
| Professional | | $1,494.67 | $1,761.89 | $3,215.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.04 / $1,495.29 / $1,996.01
| Professional | | $974.04 | $1,495.29 | $1,996.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.31 / $1,323.06 / $1,996.01
| Professional | | $921.31 | $1,323.06 | $1,996.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.94 / $1,253.66 / $3,644.47
| Professional | | $1,090.94 | $1,253.66 | $3,644.47 |