- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $630.96 / $1,348.96
| Professional | | $524.81 | $630.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $912.01 / $1,202.26
| Professional | | $524.81 | $912.01 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,348.96
| Professional | | $676.08 | $870.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,202.26
| Professional | | $645.65 | $794.33 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $831.76 / $1,621.81
| Professional | | $575.44 | $831.76 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $831.76 / $1,318.26
| Professional | | $588.84 | $831.76 | $1,318.26 |