- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.14 / $1,156.40 / $2,539.34
| Professional | | $1,059.14 | $1,156.40 | $2,539.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.59 / $1,157.68 / $1,425.00
| Professional | | $1,016.59 | $1,157.68 | $1,425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.85 / $1,227.64 / $2,380.29
| Professional | | $885.85 | $1,227.64 | $2,380.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.09 / $1,252.71 / $2,060.16
| Professional | | $971.09 | $1,252.71 | $2,060.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.72 / $1,090.11 / $1,817.48
| Professional | | $858.72 | $1,090.11 | $1,817.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.08 / $852.08 / $1,360.86
| Professional | | $852.08 | $852.08 | $1,360.86 |