- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.48 / $341.48 / $341.48
| Facility | | $341.48 | $341.48 | $341.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.48 / $341.48 / $341.48
| Professional | | $341.48 | $341.48 | $341.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.00 / $447.00 / $570.35
| Professional | | $447.00 | $447.00 | $570.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.39 / $364.39 / $364.39
| Professional | | $364.39 | $364.39 | $364.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.30 / $542.30 / $1,656.20
| Professional | | $542.30 | $542.30 | $1,656.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.49 / $416.24 / $625.40
| Professional | | $277.49 | $416.24 | $625.40 |