- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Facility | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.26 / $251.26 / $251.26
| Professional | | $251.26 | $251.26 | $251.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.42 / $231.42 / $245.30
| Facility | | $231.42 | $231.42 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $312.41
| Professional | | $245.30 | $245.30 | $312.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.51 / $208.51 / $413.87
| Professional | | $208.51 | $208.51 | $413.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $397.58
| Professional | | $245.30 | $245.30 | $397.58 |