- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.62 / $727.62 / $727.62
| Professional | | $727.62 | $727.62 | $727.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.62 / $984.26 / $1,493.78
| Professional | | $836.62 | $984.26 | $1,493.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.48 / $1,267.74 / $1,959.22
| Professional | | $704.48 | $1,267.74 | $1,959.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.96 / $1,358.60 / $2,012.67
| Professional | | $1,133.96 | $1,358.60 | $2,012.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.62 / $727.62 / $727.62
| Professional | | $727.62 | $727.62 | $727.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.02 / $1,249.58 / $1,805.97
| Professional | | $884.02 | $1,249.58 | $1,805.97 |