- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.46 / $587.46 / $711.57
| Professional | | $587.46 | $587.46 | $711.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.50 / $841.44 / $1,233.56
| Professional | | $700.50 | $841.44 | $1,233.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.92 / $919.46 / $1,330.84
| Professional | | $764.92 | $919.46 | $1,330.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.38 / $925.22 / $1,419.33
| Professional | | $718.38 | $925.22 | $1,419.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.46 / $587.46 / $711.57
| Professional | | $587.46 | $587.46 | $711.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.91 / $978.96 / $1,292.11
| Professional | | $739.91 | $978.96 | $1,292.11 |