- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.64 / $1,152.90 / $1,889.08
| Professional | | $1,015.64 | $1,152.90 | $1,889.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.85 / $1,016.68 / $1,410.00
| Professional | | $1,010.85 | $1,016.68 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.30 / $1,306.18 / $2,392.42
| Professional | | $882.30 | $1,306.18 | $2,392.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.52 / $1,246.81 / $2,048.39
| Professional | | $966.52 | $1,246.81 | $2,048.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.63 / $1,101.70 / $2,065.42
| Professional | | $823.63 | $1,101.70 | $2,065.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.24 / $774.24 / $1,354.82
| Professional | | $774.24 | $774.24 | $1,354.82 |