- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.09 / $230.09 / $230.09
| Facility | | $230.09 | $230.09 | $230.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.09 / $230.09 / $230.09
| Professional | | $230.09 | $230.09 | $230.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.00 / $231.00 / $295.08
| Professional | | $231.00 | $231.00 | $295.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.86 / $203.86 / $203.86
| Professional | | $203.86 | $203.86 | $203.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.58 / $280.58 / $856.91
| Professional | | $280.58 | $280.58 | $856.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.57 / $215.36 / $305.08
| Professional | | $143.57 | $215.36 | $305.08 |