- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.56 / $1,116.20 / $2,298.12
| Professional | | $1,022.56 | $1,116.20 | $2,298.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.27 / $1,095.27 / $1,251.89
| Professional | | $1,095.27 | $1,095.27 | $1,251.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.19 / $1,110.41 / $2,296.92
| Professional | | $855.19 | $1,110.41 | $2,296.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.67 / $1,209.58 / $1,988.12
| Professional | | $937.67 | $1,209.58 | $1,988.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.01 / $1,054.08 / $1,756.58
| Professional | | $801.01 | $1,054.08 | $1,756.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.60 / $788.60 / $1,313.91
| Professional | | $788.60 | $788.60 | $1,313.91 |