- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.33 / $343.33 / $343.33
| Facility | | $343.33 | $343.33 | $343.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.33 / $343.33 / $343.33
| Professional | | $343.33 | $343.33 | $343.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.00 / $345.00 / $345.00
| Professional | | $345.00 | $345.00 | $345.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.45 / $301.45 / $301.45
| Professional | | $301.45 | $301.45 | $301.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.68 / $418.68 / $1,278.63
| Professional | | $418.68 | $418.68 | $1,278.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.23 / $321.35 / $455.24
| Professional | | $214.23 | $321.35 | $455.24 |