- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,509.35
| Professional | | $1,494.41 | $1,494.41 | $1,509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,920.73 / $1,920.73
| Professional | | $1,494.41 | $1,920.73 | $1,920.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.89 / $2,447.00 / $2,814.05
| Professional | | $2,128.89 | $2,447.00 | $2,814.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.85 / $1,793.29 / $2,092.17
| Professional | | $1,643.85 | $1,793.29 | $2,092.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,728.65 / $2,241.62
| Professional | | $1,494.41 | $1,728.65 | $2,241.62 |