- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.60 / $685.60 / $1,165.47
| Professional | | $685.60 | $685.60 | $1,165.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.40 / $910.93 / $1,445.87
| Professional | | $795.40 | $910.93 | $1,445.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.45 / $1,029.95 / $1,475.58
| Professional | | $811.45 | $1,029.95 | $1,475.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.52 / $987.21 / $1,514.43
| Professional | | $766.52 | $987.21 | $1,514.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.60 / $685.60 / $1,165.47
| Professional | | $685.60 | $685.60 | $1,165.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.39 / $1,006.52 / $1,505.22
| Professional | | $729.39 | $1,006.52 | $1,505.22 |