- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.03 / $1,239.01 / $2,111.40
| Professional | | $1,021.03 | $1,239.01 | $2,111.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,355.75 / $1,549.63
| Professional | | $1,080.00 | $1,355.75 | $1,549.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.76 / $1,597.88 / $2,926.69
| Professional | | $1,080.76 | $1,597.88 | $2,926.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.68 / $1,578.28 / $2,531.19
| Professional | | $1,186.68 | $1,578.28 | $2,531.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.26 / $1,281.33 / $2,316.02
| Professional | | $966.26 | $1,281.33 | $2,316.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.92 / $1,364.68 / $1,665.88
| Professional | | $909.92 | $1,364.68 | $1,665.88 |