- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.31 / $207.31 / $207.31
| Facility | | $207.31 | $207.31 | $207.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.83 / $207.31 / $207.31
| Professional | | $204.83 | $207.31 | $207.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.14 / $321.00 / $663.00
| Professional | | $259.14 | $321.00 | $663.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.53 / $414.53 / $414.53
| Facility | | $414.53 | $414.53 | $414.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.05 / $337.14 / $460.90
| Professional | | $101.05 | $337.14 | $460.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $87.07 / $207.31
| Professional | | $87.07 | $87.07 | $207.31 |