- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $701.68 / $701.68 / $701.68
| Facility | | $701.68 | $701.68 | $701.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.56 / $751.56 / $890.93
| Professional | | $751.56 | $751.56 | $890.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.77 / $477.77 / $477.77
| Professional | | $477.77 | $477.77 | $477.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,082.35 / $1,082.35
| Professional | | $150.00 | $1,082.35 | $1,082.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.56 / $1,157.40 / $2,028.99
| Facility | | $751.56 | $1,157.40 | $2,028.99 |