- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.37 / $897.37 / $1,085.10
| Professional | | $897.37 | $897.37 | $1,085.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.11 / $1,222.44 / $1,765.76
| Professional | | $1,037.11 | $1,222.44 | $1,765.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.71 / $1,314.08 / $2,024.10
| Professional | | $1,143.71 | $1,314.08 | $2,024.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.77 / $1,317.24 / $2,020.72
| Professional | | $1,022.77 | $1,317.24 | $2,020.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.37 / $897.37 / $1,085.10
| Professional | | $897.37 | $897.37 | $1,085.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.67 / $1,330.69 / $1,853.87
| Professional | | $1,077.67 | $1,330.69 | $1,853.87 |