- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.86 / $1,219.71 / $2,285.51
| Professional | | $1,104.86 | $1,219.71 | $2,285.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.42 / $1,034.42 / $1,500.00
| Professional | | $1,034.42 | $1,034.42 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.37 / $1,222.19 / $2,506.11
| Professional | | $933.37 | $1,222.19 | $2,506.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.24 / $1,316.11 / $2,181.65
| Professional | | $1,020.24 | $1,316.11 | $2,181.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.08 / $1,175.44 / $2,182.10
| Professional | | $869.08 | $1,175.44 | $2,182.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.57 / $802.57 / $1,431.20
| Professional | | $802.57 | $802.57 | $1,431.20 |