- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.67 / $1,237.25 / $1,237.25
| Professional | | $1,007.67 | $1,237.25 | $1,237.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.98 / $1,042.79 / $1,576.20
| Professional | | $855.98 | $1,042.79 | $1,576.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.36 / $1,237.25 / $1,725.86
| Professional | | $1,040.36 | $1,237.25 | $1,725.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.27 / $995.46 / $1,548.94
| Professional | | $894.27 | $995.46 | $1,548.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.85 / $1,007.67 / $1,237.25
| Professional | | $841.85 | $1,007.67 | $1,237.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.27 / $1,221.83 / $1,548.94
| Professional | | $894.27 | $1,221.83 | $1,548.94 |