- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.43 / $265.43 / $265.43
| Facility | | $265.43 | $265.43 | $265.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.43 / $265.43 / $302.41
| Professional | | $265.43 | $265.43 | $302.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.00 / $348.00 / $348.00
| Professional | | $348.00 | $348.00 | $348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.42 / $233.42 / $233.42
| Professional | | $233.42 | $233.42 | $233.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.55 / $421.55 / $1,287.39
| Professional | | $421.55 | $421.55 | $1,287.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.70 / $323.54 / $486.12
| Professional | | $215.70 | $323.54 | $486.12 |