- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,441.72
| Professional | | $1,427.45 | $1,427.45 | $1,441.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,488.74 / $1,751.46
| Professional | | $1,427.45 | $1,488.74 | $1,751.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.22 / $2,231.35 / $2,514.51
| Professional | | $2,008.22 | $2,231.35 | $2,514.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.20 / $1,712.94 / $1,998.43
| Professional | | $1,570.20 | $1,712.94 | $1,998.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,576.31 / $2,141.17
| Professional | | $1,427.45 | $1,576.31 | $2,141.17 |