- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.75 / $747.75 / $1,491.89
| Professional | | $747.75 | $747.75 | $1,491.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.08 / $1,160.48 / $1,779.77
| Professional | | $915.08 | $1,160.48 | $1,779.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.36 / $1,292.64 / $2,003.38
| Professional | | $720.36 | $1,292.64 | $2,003.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.10 / $1,397.12 / $2,069.73
| Professional | | $1,166.10 | $1,397.12 | $2,069.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.75 / $966.48 / $1,491.89
| Professional | | $747.75 | $966.48 | $1,491.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.68 / $1,291.35 / $1,855.16
| Professional | | $907.68 | $1,291.35 | $1,855.16 |