- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,989.59
| Professional | | $1,969.89 | $1,969.89 | $1,989.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $1,969.89 / $1,969.89
| Professional | | $1,969.89 | $1,969.89 | $1,969.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.66 / $2,404.21 / $2,640.42
| Professional | | $2,091.66 | $2,404.21 | $2,640.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.88 / $2,363.86 / $2,757.84
| Professional | | $2,166.88 | $2,363.86 | $2,757.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.89 / $2,170.14 / $2,954.84
| Professional | | $1,969.89 | $2,170.14 | $2,954.84 |