- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,466.78
| Professional | | $1,452.25 | $1,452.25 | $1,466.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,869.59 / $1,869.59
| Professional | | $1,452.25 | $1,869.59 | $1,869.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,933.47 / $2,274.67 / $2,615.87
| Professional | | $1,933.47 | $2,274.67 | $2,615.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.48 / $1,742.70 / $2,033.15
| Professional | | $1,597.48 | $1,742.70 | $2,033.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,682.63 / $2,178.38
| Professional | | $1,452.25 | $1,682.63 | $2,178.38 |