- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.72 / $812.72 / $812.72
| Professional | | $812.72 | $812.72 | $812.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.09 / $1,249.11 / $1,952.09
| Professional | | $989.09 | $1,249.11 | $1,952.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.06 / $1,353.14 / $2,202.77
| Professional | | $792.06 | $1,353.14 | $2,202.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.76 / $1,528.49 / $2,264.35
| Professional | | $1,275.76 | $1,528.49 | $2,264.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.72 / $812.72 / $812.72
| Professional | | $812.72 | $812.72 | $812.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.17 / $1,355.40 / $2,037.14
| Professional | | $985.17 | $1,355.40 | $2,037.14 |