- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.56 / $2,096.56 / $2,096.56
| Professional | | $2,096.56 | $2,096.56 | $2,096.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.08 / $2,147.08 / $3,239.57
| Professional | | $2,147.08 | $2,147.08 | $3,239.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.00 / $425.00 / $445.03
| Professional | | $425.00 | $425.00 | $445.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,639.65 / $2,879.62 / $2,999.60
| Professional | | $2,639.65 | $2,879.62 | $2,999.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.98 / $3,157.47 / $3,239.57
| Professional | | $2,104.98 | $3,157.47 | $3,239.57 |