- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.06 / $976.20 / $976.20
| Professional | | $707.06 | $976.20 | $976.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.18 / $1,084.65 / $1,566.74
| Professional | | $926.18 | $1,084.65 | $1,566.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.93 / $1,162.79 / $1,804.77
| Professional | | $969.93 | $1,162.79 | $1,804.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.64 / $1,165.09 / $1,787.32
| Professional | | $904.64 | $1,165.09 | $1,787.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.06 / $976.20 / $976.20
| Professional | | $707.06 | $976.20 | $976.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.56 / $1,144.16 / $1,721.60
| Professional | | $775.56 | $1,144.16 | $1,721.60 |