- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.41 / $791.41 / $949.69
| Facility | | $791.41 | $791.41 | $949.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.41 / $791.41 / $791.41
| Professional | | $791.41 | $791.41 | $791.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.01 / $8.01 / $8.01
| Professional | | $8.01 | $8.01 | $8.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.26 / $271.26 / $271.26
| Professional | | $271.26 | $271.26 | $271.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.65 / $2,024.61 / $3,328.36
| Professional | | $1,352.65 | $2,024.61 | $3,328.36 |