- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Professional | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,238.72
| Professional | | $912.01 | $1,071.52 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $851.14 / $1,318.26
| Professional | | $691.83 | $851.14 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $588.84
| Professional | | $512.86 | $512.86 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,584.89
| Professional | | $691.83 | $912.01 | $1,584.89 |