- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.30 / $1,155.60 / $2,602.14
| Professional | | $1,057.30 | $1,155.60 | $2,602.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.69 / $1,091.69 / $1,770.00
| Professional | | $1,091.69 | $1,091.69 | $1,770.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.61 / $1,181.46 / $2,378.69
| Professional | | $884.61 | $1,181.46 | $2,378.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.65 / $1,250.84 / $2,056.17
| Professional | | $969.65 | $1,250.84 | $2,056.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.74 / $1,078.13 / $1,815.57
| Professional | | $824.74 | $1,078.13 | $1,815.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.82 / $764.82 / $1,358.91
| Professional | | $764.82 | $764.82 | $1,358.91 |