- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.55 / $742.55 / $1,276.82
| Professional | | $742.55 | $742.55 | $1,276.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.24 / $987.40 / $1,563.91
| Professional | | $860.24 | $987.40 | $1,563.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.39 / $1,114.18 / $1,596.26
| Professional | | $890.39 | $1,114.18 | $1,596.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.10 / $1,067.82 / $1,638.09
| Professional | | $829.10 | $1,067.82 | $1,638.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.55 / $742.55 / $1,276.82
| Professional | | $742.55 | $742.55 | $1,276.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.24 / $1,053.84 / $1,480.06
| Professional | | $748.24 | $1,053.84 | $1,480.06 |