- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.54 / $1,173.54 / $1,376.52
| Professional | | $1,173.54 | $1,173.54 | $1,376.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.10 / $1,410.74 / $2,089.19
| Professional | | $1,235.10 | $1,410.74 | $2,089.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.70 / $1,455.27 / $2,179.60
| Professional | | $929.70 | $1,455.27 | $2,179.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.52 / $1,520.40 / $2,332.38
| Professional | | $1,180.52 | $1,520.40 | $2,332.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.73 / $1,173.54 / $1,376.52
| Professional | | $942.73 | $1,173.54 | $1,376.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.06 / $1,464.27 / $2,026.70
| Professional | | $1,016.06 | $1,464.27 | $2,026.70 |