- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.66 / $950.77 / $950.77
| Professional | | $663.66 | $950.77 | $950.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.15 / $1,036.67 / $1,497.44
| Professional | | $896.15 | $1,036.67 | $1,497.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.04 / $1,109.11 / $1,772.80
| Professional | | $860.04 | $1,109.11 | $1,772.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.13 / $1,115.51 / $1,711.25
| Professional | | $866.13 | $1,115.51 | $1,711.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.66 / $950.77 / $950.77
| Professional | | $663.66 | $950.77 | $950.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.77 / $1,064.35 / $1,581.16
| Professional | | $745.77 | $1,064.35 | $1,581.16 |