- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.76 / $1,017.76 / $1,146.74
| Professional | | $1,017.76 | $1,017.76 | $1,146.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.93 / $1,054.82 / $1,624.73
| Professional | | $958.93 | $1,054.82 | $1,624.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.95 / $1,187.40 / $1,701.16
| Professional | | $951.95 | $1,187.40 | $1,701.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.54 / $1,137.92 / $1,745.63
| Professional | | $883.54 | $1,137.92 | $1,745.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.51 / $1,017.76 / $1,146.74
| Professional | | $878.51 | $1,017.76 | $1,146.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.19 / $1,239.46 / $1,737.91
| Professional | | $960.19 | $1,239.46 | $1,737.91 |