- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.96 / $881.96 / $881.96
| Professional | | $881.96 | $881.96 | $881.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.21 / $903.21 / $1,362.78
| Professional | | $903.21 | $903.21 | $1,362.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $523.55
| Professional | | $500.00 | $500.00 | $523.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.42 / $1,211.35 / $1,261.83
| Professional | | $1,110.42 | $1,211.35 | $1,261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.50 / $1,328.25 / $1,362.78
| Professional | | $885.50 | $1,328.25 | $1,362.78 |