- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $230.92 / $230.92
| Facility | | $230.92 | $230.92 | $230.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.51 / $230.92 / $235.00
| Professional | | $215.51 | $230.92 | $235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $261.94 / $327.43
| Professional | | $20.00 | $261.94 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.26 / $278.36 / $657.86
| Professional | | $227.26 | $278.36 | $657.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.83 / $277.23 / $540.74
| Professional | | $250.83 | $277.23 | $540.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.01 / $253.58 / $619.54
| Professional | | $179.01 | $253.58 | $619.54 |