- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.41 / $791.41 / $791.41
| Facility | | $791.41 | $791.41 | $791.41 |
- 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
- $271.26 / $271.26 / $271.26
| Professional | | $271.26 | $271.26 | $271.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.54 / $1,518.13 / $2,212.35
| Facility | | $1,183.54 | $1,518.13 | $2,212.35 |