- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.36 / $41.36 / $41.36
| Facility | | $41.36 | $41.36 | $41.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.25 / $855.25 / $1,124.07
| Professional | | $855.25 | $855.25 | $1,124.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.33 / $881.33 / $881.33
| Professional | | $881.33 | $881.33 | $881.33 |
- 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
- $855.25 / $1,317.09 / $2,028.99
| Facility | | $855.25 | $1,317.09 | $2,028.99 |