- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.95 / $218.86 / $1,782.00
| Facility | | $106.95 | $218.86 | $1,782.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.08 / $272.70 / $292.93
| Professional | | $263.08 | $272.70 | $292.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.70 / $272.70 / $272.70
| Facility | | $272.70 | $272.70 | $272.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.70 / $272.70 / $272.70
| Professional | | $272.70 | $272.70 | $272.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.80 / $267.37 / $304.80
| Professional | | $254.80 | $267.37 | $304.80 |