- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.14 / $970.44 / $970.44
| Professional | | $720.14 | $970.44 | $970.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.06 / $1,057.35 / $1,519.06
| Professional | | $957.06 | $1,057.35 | $1,519.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.62 / $1,193.17 / $1,688.31
| Professional | | $958.62 | $1,193.17 | $1,688.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.09 / $1,145.07 / $1,756.60
| Professional | | $889.09 | $1,145.07 | $1,756.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.14 / $970.44 / $970.44
| Professional | | $720.14 | $970.44 | $970.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.35 / $1,166.84 / $1,553.28
| Professional | | $841.35 | $1,166.84 | $1,553.28 |