- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.77 / $700.77 / $768.27
| Professional | | $700.77 | $700.77 | $768.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.80 / $1,084.24 / $2,343.17
| Professional | | $919.80 | $1,084.24 | $2,343.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.25 / $978.49 / $1,370.82
| Professional | | $688.25 | $978.49 | $1,370.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.59 / $905.22 / $1,370.82
| Professional | | $626.59 | $905.22 | $1,370.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.88 / $860.99 / $2,502.94
| Professional | | $713.88 | $860.99 | $2,502.94 |