- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.27 / $1,197.17 / $2,439.17
| Professional | | $1,094.27 | $1,197.17 | $2,439.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.21 / $1,158.21 / $1,410.00
| Professional | | $1,158.21 | $1,158.21 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.46 / $1,270.00 / $2,464.02
| Professional | | $918.46 | $1,270.00 | $2,464.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.63 / $1,298.55 / $2,129.04
| Professional | | $1,006.63 | $1,298.55 | $2,129.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.63 / $1,223.82 / $2,154.58
| Professional | | $857.63 | $1,223.82 | $2,154.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.01 / $867.01 / $1,410.76
| Professional | | $867.01 | $867.01 | $1,410.76 |