- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,162.28
| Professional | | $2,951.21 | $2,951.21 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $2,754.23
| Professional | | $2,187.76 | $2,511.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $218.78
| Professional | | $144.54 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $190.55 / $2,818.38
| Professional | | $125.89 | $190.55 | $2,818.38 |