- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $318.22
| Facility | | $318.22 | $318.22 | $318.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $318.22
| Professional | | $318.22 | $318.22 | $318.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.29 / $333.29 / $408.12
| Professional | | $333.29 | $333.29 | $408.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.86 / $277.86 / $277.86
| Professional | | $277.86 | $277.86 | $277.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.06 / $388.06 / $1,185.13
| Professional | | $388.06 | $388.06 | $1,185.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.56 / $290.27 / $421.95
| Professional | | $198.56 | $290.27 | $421.95 |