- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.41 / $779.80 / $1,361.94
| Professional | | $748.41 | $779.80 | $1,361.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.68 / $1,036.00 / $1,640.05
| Professional | | $904.68 | $1,036.00 | $1,640.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.65 / $1,169.40 / $1,675.37
| Professional | | $956.65 | $1,169.40 | $1,675.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.46 / $1,119.80 / $1,717.84
| Professional | | $869.46 | $1,119.80 | $1,717.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.41 / $779.80 / $1,361.94
| Professional | | $748.41 | $779.80 | $1,361.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.56 / $1,125.32 / $1,712.03
| Professional | | $962.56 | $1,125.32 | $1,712.03 |