- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.42 / $1,005.62 / $1,135.00
| Professional | | $825.42 | $1,005.62 | $1,135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.77 / $1,213.58 / $1,744.50
| Professional | | $937.77 | $1,213.58 | $1,744.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.13 / $1,363.85 / $2,039.50
| Professional | | $946.13 | $1,363.85 | $2,039.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.32 / $1,318.19 / $2,022.18
| Professional | | $1,139.32 | $1,318.19 | $2,022.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.21 / $1,026.33 / $1,135.00
| Professional | | $758.21 | $1,026.33 | $1,135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.20 / $1,167.46 / $1,856.32
| Professional | | $772.20 | $1,167.46 | $1,856.32 |