- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.09 / $987.44 / $987.44
| Professional | | $709.09 | $987.44 | $987.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.03 / $1,100.94 / $1,590.27
| Professional | | $937.03 | $1,100.94 | $1,590.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.72 / $1,178.83 / $1,839.50
| Professional | | $923.72 | $1,178.83 | $1,839.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.20 / $1,185.14 / $1,818.07
| Professional | | $920.20 | $1,185.14 | $1,818.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.09 / $987.44 / $987.44
| Professional | | $709.09 | $987.44 | $987.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.18 / $1,110.80 / $1,677.61
| Professional | | $879.18 | $1,110.80 | $1,677.61 |