- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.36 / $920.96 / $1,030.34
| Professional | | $699.36 | $920.96 | $1,030.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.17 / $1,097.63 / $1,612.59
| Professional | | $848.17 | $1,097.63 | $1,612.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.19 / $1,259.65 / $1,870.65
| Professional | | $873.19 | $1,259.65 | $1,870.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.17 / $1,218.52 / $1,869.27
| Professional | | $1,053.17 | $1,218.52 | $1,869.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.36 / $919.34 / $1,030.34
| Professional | | $699.36 | $919.34 | $1,030.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.56 / $1,062.92 / $1,709.17
| Professional | | $741.56 | $1,062.92 | $1,709.17 |