- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.11 / $1,707.11 / $1,707.11
| Professional | | $1,707.11 | $1,707.11 | $1,707.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $2,637.79
| Professional | | $1,748.25 | $1,748.25 | $2,637.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.00 / $455.00 / $476.44
| Professional | | $455.00 | $455.00 | $476.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.31 / $2,344.69 / $2,442.40
| Professional | | $2,149.31 | $2,344.69 | $2,442.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $2,570.96 / $2,637.79
| Professional | | $1,713.97 | $2,570.96 | $2,637.79 |