- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.08 / $265.08 / $265.08
| Facility | | $265.08 | $265.08 | $265.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.08 / $265.08 / $265.08
| Professional | | $265.08 | $265.08 | $265.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.00 / $278.70 / $339.98
| Professional | | $267.00 | $278.70 | $339.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.47 / $230.47 / $230.47
| Professional | | $230.47 | $230.47 | $230.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.27 / $323.27 / $987.26
| Professional | | $323.27 | $323.27 | $987.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.41 / $248.12 / $351.50
| Professional | | $165.41 | $248.12 | $351.50 |