- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.74 / $1,474.03 / $1,474.03
| Professional | | $1,077.74 | $1,474.03 | $1,474.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.24 / $1,264.30 / $1,860.53
| Professional | | $1,022.24 | $1,264.30 | $1,860.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.47 / $1,474.03 / $2,070.48
| Professional | | $1,212.47 | $1,474.03 | $2,070.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.24 / $1,206.92 / $1,877.97
| Professional | | $1,084.24 | $1,206.92 | $1,877.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.74 / $1,474.03 / $1,474.03
| Professional | | $1,077.74 | $1,474.03 | $1,474.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.79 / $1,396.41 / $1,877.97
| Professional | | $1,020.79 | $1,396.41 | $1,877.97 |