- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.44 / $720.44 / $786.94
| Professional | | $720.44 | $720.44 | $786.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.71 / $1,107.70 / $2,403.86
| Professional | | $939.71 | $1,107.70 | $2,403.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.84 / $1,011.20 / $1,400.38
| Professional | | $704.84 | $1,011.20 | $1,400.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.63 / $924.42 / $1,400.38
| Professional | | $639.63 | $924.42 | $1,400.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.76 / $879.55 / $2,556.91
| Professional | | $737.76 | $879.55 | $2,556.91 |