- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.32 / $711.73 / $711.73
| Professional | | $544.32 | $711.73 | $711.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.23 / $972.37 / $1,350.81
| Professional | | $748.23 | $972.37 | $1,350.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.41 / $1,092.24 / $1,765.81
| Professional | | $665.41 | $1,092.24 | $1,765.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.70 / $1,060.36 / $1,767.56
| Professional | | $827.70 | $1,060.36 | $1,767.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.32 / $544.32 / $711.73
| Professional | | $544.32 | $544.32 | $711.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.86 / $1,160.41 / $1,723.05
| Professional | | $848.86 | $1,160.41 | $1,723.05 |