- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.09 / $1,041.09 / $1,052.51
| Professional | | $1,041.09 | $1,041.09 | $1,052.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.20 / $1,367.00 / $2,125.28
| Professional | | $1,182.20 | $1,367.00 | $2,125.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.07 / $1,531.04 / $2,202.56
| Professional | | $1,142.07 | $1,531.04 | $2,202.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.00 / $1,483.68 / $2,276.04
| Professional | | $1,152.00 | $1,483.68 | $2,276.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.09 / $1,041.09 / $1,052.51
| Professional | | $1,041.09 | $1,041.09 | $1,052.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.10 / $1,399.19 / $2,014.54
| Professional | | $995.10 | $1,399.19 | $2,014.54 |