- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $954.99 / $1,698.24
| Professional | | $512.86 | $954.99 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $1,698.24
| Professional | | $691.83 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,698.24
| Professional | | $912.01 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $1,513.56
| Professional | | $954.99 | $1,148.15 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $2,290.87
| Professional | | $870.96 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,513.56
| Professional | | $831.76 | $1,096.48 | $1,513.56 |