- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.56 / $940.60 / $940.60
| Professional | | $675.56 | $940.60 | $940.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.25 / $771.63 / $1,186.90
| Professional | | $633.25 | $771.63 | $1,186.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.42 / $940.60 / $1,276.38
| Professional | | $769.42 | $940.60 | $1,276.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.73 / $736.60 / $1,146.15
| Professional | | $661.73 | $736.60 | $1,146.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.56 / $940.60 / $940.60
| Professional | | $675.56 | $940.60 | $940.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.81 / $880.19 / $1,138.18
| Professional | | $702.81 | $880.19 | $1,138.18 |