- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.49 / $1,208.70 / $2,539.00
| Professional | | $1,102.49 | $1,208.70 | $2,539.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.61 / $1,298.80 / $1,484.53
| Professional | | $1,062.61 | $1,298.80 | $1,484.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.61 / $1,300.41 / $2,486.91
| Professional | | $926.61 | $1,300.41 | $2,486.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.38 / $1,309.83 / $2,146.52
| Professional | | $1,015.38 | $1,309.83 | $2,146.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.44 / $1,206.48 / $2,020.22
| Professional | | $877.44 | $1,206.48 | $2,020.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.63 / $896.63 / $1,423.10
| Professional | | $896.63 | $896.63 | $1,423.10 |