- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.86 / $234.86 / $246.30
| Facility | | $234.86 | $234.86 | $246.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.86 / $234.86 / $271.67
| Professional | | $234.86 | $234.86 | $271.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.00 / $645.00 / $1,061.00
| Professional | | $645.00 | $645.00 | $1,061.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.68 / $451.68 / $928.16
| Professional | | $451.68 | $451.68 | $928.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.16 / $489.19 / $911.91
| Professional | | $288.16 | $489.19 | $911.91 |