- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.13 / $1,084.54 / $1,967.07
| Professional | | $1,009.13 | $1,084.54 | $1,967.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.48 / $1,346.70 / $2,116.42
| Professional | | $1,174.48 | $1,346.70 | $2,116.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.85 / $1,510.00 / $2,163.34
| Professional | | $1,248.85 | $1,510.00 | $2,163.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.01 / $1,445.06 / $2,216.80
| Professional | | $1,122.01 | $1,445.06 | $2,216.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.13 / $1,009.13 / $1,967.07
| Professional | | $1,009.13 | $1,009.13 | $1,967.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.04 / $1,437.54 / $1,999.67
| Professional | | $1,028.04 | $1,437.54 | $1,999.67 |