- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.33 / $694.46 / $694.46
| Professional | | $575.33 | $694.46 | $694.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $920.65 / $1,406.71
| Professional | | $766.45 | $920.65 | $1,406.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.76 / $1,195.14 / $1,722.97
| Professional | | $677.76 | $1,195.14 | $1,722.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.01 / $1,103.44 / $1,825.86
| Professional | | $899.01 | $1,103.44 | $1,825.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.33 / $575.33 / $694.46
| Professional | | $575.33 | $575.33 | $694.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.68 / $1,108.34 / $1,746.28
| Professional | | $833.68 | $1,108.34 | $1,746.28 |