- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.34 / $232.34 / $232.34
| Facility | | $232.34 | $232.34 | $232.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.34 / $246.22 / $246.22
| Professional | | $232.34 | $246.22 | $246.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.01 / $1,391.62 / $1,709.52
| Facility | | $277.01 | $1,391.62 | $1,709.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.05 / $293.08 / $1,133.47
| Professional | | $237.05 | $293.08 | $1,133.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.21 / $239.41 / $497.75
| Professional | | $161.21 | $239.41 | $497.75 |