- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $315.43
| Facility | | $315.43 | $315.43 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $315.43
| Professional | | $315.43 | $315.43 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.00 / $317.00 / $317.00
| Professional | | $317.00 | $317.00 | $317.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.57 / $292.57 / $292.57
| Professional | | $292.57 | $292.57 | $292.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.66 / $384.66 / $1,174.72
| Professional | | $384.66 | $384.66 | $1,174.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.82 / $295.24 / $418.25
| Professional | | $196.82 | $295.24 | $418.25 |