- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $368.53 / $368.53
| Facility | | $246.23 | $368.53 | $368.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $246.23
| Professional | | $246.23 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.47 / $245.00 / $267.05
| Professional | | $115.47 | $245.00 | $267.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.53 / $277.67 / $317.33
| Facility | | $255.53 | $277.67 | $317.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $218.00 / $218.00
| Professional | | $135.00 | $218.00 | $218.00 |