- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $259.16 / $259.16 / $259.16
| Facility | | $259.16 | $259.16 | $259.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.16 / $259.16 / $259.16
| Professional | | $259.16 | $259.16 | $259.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.00 / $261.00 / $261.00
| Professional | | $261.00 | $261.00 | $261.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.60 / $227.60 / $227.60
| Professional | | $227.60 | $227.60 | $227.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.04 / $316.04 / $965.17
| Professional | | $316.04 | $316.04 | $965.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.71 / $242.57 / $343.64
| Professional | | $161.71 | $242.57 | $343.64 |