- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,089.16
| Professional | | $2,068.46 | $2,068.46 | $2,089.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,458.10 / $2,825.40 / $3,249.21
| Professional | | $2,458.10 | $2,825.40 | $3,249.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.32 / $2,482.17 / $2,895.86
| Professional | | $2,275.32 | $2,482.17 | $2,895.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,670.50 / $3,102.71
| Professional | | $2,068.46 | $2,670.50 | $3,102.71 |