- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.84 / $719.84 / $737.19
| Professional | | $719.84 | $719.84 | $737.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.65 / $1,041.64 / $2,241.33
| Professional | | $883.65 | $1,041.64 | $2,241.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.92 / $999.38 / $1,396.43
| Professional | | $683.92 | $999.38 | $1,396.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.34 / $926.74 / $1,396.43
| Professional | | $646.34 | $926.74 | $1,396.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.46 / $862.79 / $2,549.71
| Professional | | $686.46 | $862.79 | $2,549.71 |