- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.01 / $981.63 / $1,611.38
| Professional | | $817.01 | $981.63 | $1,611.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.47 / $1,390.49 / $1,986.86
| Professional | | $1,074.47 | $1,390.49 | $1,986.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.11 / $1,537.03 / $2,220.52
| Professional | | $1,048.11 | $1,537.03 | $2,220.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.60 / $1,501.33 / $2,303.13
| Professional | | $1,297.60 | $1,501.33 | $2,303.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.34 / $1,318.89 / $1,934.26
| Professional | | $865.34 | $1,318.89 | $1,934.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.09 / $1,454.42 / $2,059.60
| Professional | | $902.09 | $1,454.42 | $2,059.60 |