- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.32 / $318.32 / $318.32
| Facility | | $318.32 | $318.32 | $318.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.32 / $318.32 / $318.32
| Professional | | $318.32 | $318.32 | $318.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.00 / $320.00 / $320.00
| Professional | | $320.00 | $320.00 | $320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.16 / $218.16 / $218.16
| Professional | | $218.16 | $218.16 | $218.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.18 / $388.18 / $1,185.47
| Professional | | $388.18 | $388.18 | $1,185.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.62 / $297.94 / $509.23
| Professional | | $198.62 | $297.94 | $509.23 |