- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.69 / $941.69 / $1,613.82
| Professional | | $941.69 | $941.69 | $1,613.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.82 / $1,255.20 / $1,975.32
| Professional | | $1,094.82 | $1,255.20 | $1,975.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.18 / $1,408.65 / $2,018.14
| Professional | | $1,152.18 | $1,408.65 | $2,018.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.21 / $1,348.71 / $2,069.00
| Professional | | $1,047.21 | $1,348.71 | $2,069.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.69 / $941.69 / $1,613.82
| Professional | | $941.69 | $941.69 | $1,613.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.41 / $1,340.74 / $1,866.93
| Professional | | $1,036.41 | $1,340.74 | $1,866.93 |