- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $602.56 / $1,047.13
| Professional | | $338.84 | $602.56 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $676.08 / $1,047.13
| Professional | | $426.58 | $676.08 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $691.83 / $1,047.13
| Professional | | $562.34 | $691.83 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $707.95 / $912.01
| Professional | | $588.84 | $707.95 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $724.44 / $1,348.96
| Professional | | $537.03 | $724.44 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $691.83 / $933.25
| Professional | | $489.78 | $691.83 | $933.25 |