- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.87 / $699.87 / $699.87
| Professional | | $699.87 | $699.87 | $699.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.03 / $1,085.47 / $1,678.03
| Professional | | $862.03 | $1,085.47 | $1,678.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.51 / $1,202.07 / $1,889.77
| Professional | | $679.51 | $1,202.07 | $1,889.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.51 / $1,316.12 / $1,949.75
| Professional | | $1,098.51 | $1,316.12 | $1,949.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.87 / $699.87 / $699.87
| Professional | | $699.87 | $699.87 | $699.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.55 / $1,197.70 / $1,849.45
| Professional | | $848.55 | $1,197.70 | $1,849.45 |