- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,820.44 / $2,820.44 / $2,820.44
| Professional | | $2,820.44 | $2,820.44 | $2,820.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.07 / $2,419.71 / $2,822.99
| Professional | | $2,218.07 | $2,419.71 | $2,822.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,318.17 / $3,024.63
| Professional | | $2,016.42 | $2,318.17 | $3,024.63 |