- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.05 / $253.05 / $253.05
| Facility | | $253.05 | $253.05 | $253.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.05 / $253.05 / $253.05
| Professional | | $253.05 | $253.05 | $253.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.00 / $255.00 / $255.00
| Professional | | $255.00 | $255.00 | $255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.16 / $245.16 / $245.16
| Professional | | $245.16 | $245.16 | $245.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.58 / $308.58 / $942.42
| Professional | | $308.58 | $308.58 | $942.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.90 / $236.85 / $360.30
| Professional | | $157.90 | $236.85 | $360.30 |