- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.69 / $953.56 / $953.56
| Professional | | $693.69 | $953.56 | $953.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.28 / $1,016.04 / $1,363.27
| Professional | | $868.28 | $1,016.04 | $1,363.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.07 / $1,057.78 / $1,754.74
| Professional | | $917.07 | $1,057.78 | $1,754.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.41 / $1,011.54 / $1,551.76
| Professional | | $785.41 | $1,011.54 | $1,551.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.69 / $953.56 / $953.56
| Professional | | $693.69 | $953.56 | $953.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.08 / $1,087.01 / $1,439.26
| Professional | | $773.08 | $1,087.01 | $1,439.26 |