- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.48 / $752.48 / $752.48
| Professional | | $752.48 | $752.48 | $752.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.57 / $1,191.61 / $1,883.41
| Professional | | $943.57 | $1,191.61 | $1,883.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.92 / $1,279.83 / $2,043.86
| Professional | | $734.92 | $1,279.83 | $2,043.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.83 / $1,474.66 / $2,184.60
| Professional | | $1,230.83 | $1,474.66 | $2,184.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.48 / $752.48 / $752.48
| Professional | | $752.48 | $752.48 | $752.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.57 / $1,286.76 / $1,963.21
| Professional | | $919.57 | $1,286.76 | $1,963.21 |