- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.61 / $314.61 / $314.61
| Facility | | $314.61 | $314.61 | $314.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.61 / $314.61 / $314.61
| Professional | | $314.61 | $314.61 | $314.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.00 / $412.00 / $525.47
| Professional | | $412.00 | $412.00 | $525.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.92 / $328.92 / $328.92
| Professional | | $328.92 | $328.92 | $328.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.65 / $499.65 / $1,525.89
| Professional | | $499.65 | $499.65 | $1,525.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.66 / $383.49 / $576.19
| Professional | | $255.66 | $383.49 | $576.19 |