- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.90 / $838.90 / $846.78
| Professional | | $838.90 | $838.90 | $846.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.46 / $1,352.60 / $2,567.42
| Professional | | $1,147.46 | $1,352.60 | $2,567.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.95 / $1,182.54 / $1,602.86
| Professional | | $831.95 | $1,182.54 | $1,602.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.95 / $1,064.15 / $1,602.86
| Professional | | $831.95 | $1,064.15 | $1,602.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.17 / $1,006.73 / $2,926.62
| Professional | | $837.17 | $1,006.73 | $2,926.62 |