- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.16 / $822.73 / $822.73
| Professional | | $584.16 | $822.73 | $822.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.24 / $923.54 / $1,334.02
| Professional | | $777.24 | $923.54 | $1,334.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.31 / $986.85 / $1,547.90
| Professional | | $750.31 | $986.85 | $1,547.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.48 / $991.03 / $1,520.29
| Professional | | $769.48 | $991.03 | $1,520.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.16 / $822.73 / $822.73
| Professional | | $584.16 | $822.73 | $822.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.76 / $957.96 / $1,450.95
| Professional | | $650.76 | $957.96 | $1,450.95 |