- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.70 / $1,326.31 / $1,326.31
| Professional | | $1,040.70 | $1,326.31 | $1,326.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.17 / $1,141.24 / $1,683.90
| Professional | | $925.17 | $1,141.24 | $1,683.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.79 / $1,326.31 / $1,860.92
| Professional | | $1,121.79 | $1,326.31 | $1,860.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.70 / $1,089.44 / $1,695.17
| Professional | | $978.70 | $1,089.44 | $1,695.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.70 / $1,326.31 / $1,326.31
| Professional | | $1,040.70 | $1,326.31 | $1,326.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.74 / $1,385.85 / $1,694.40
| Professional | | $1,020.74 | $1,385.85 | $1,694.40 |