- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.37 / $297.37 / $297.37
| Facility | | $297.37 | $297.37 | $297.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.37 / $297.37 / $297.37
| Professional | | $297.37 | $297.37 | $297.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.00 / $390.00 / $496.67
| Professional | | $390.00 | $390.00 | $496.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.42 / $331.42 / $331.42
| Professional | | $331.42 | $331.42 | $331.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.26 / $472.26 / $1,442.26
| Professional | | $472.26 | $472.26 | $1,442.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.65 / $362.47 / $762.43
| Professional | | $241.65 | $362.47 | $762.43 |