- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $184.38
| Facility | | $184.38 | $184.38 | $184.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $184.38
| Professional | | $184.38 | $184.38 | $184.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.28 / $71.28 / $71.28
| Professional | | $71.28 | $71.28 | $71.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,634.37 / $12,634.37 / $12,634.37
| Facility | | $12,634.37 | $12,634.37 | $12,634.37 |