- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $1,548.82
| Professional | | $1,288.25 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,584.89
| Professional | | $1,318.26 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $1,949.84
| Professional | | $1,230.27 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $1,659.59
| Professional | | $1,318.26 | $1,380.38 | $1,659.59 |