- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.35 / $120.35 / $125.72
| Facility | | $120.35 | $120.35 | $125.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.35 / $120.35 / $128.06
| Professional | | $120.35 | $120.35 | $128.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $315.00 / $518.00
| Professional | | $315.00 | $315.00 | $518.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.46 / $212.46 / $446.25
| Professional | | $212.46 | $212.46 | $446.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.94 / $222.58 / $443.31
| Professional | | $133.94 | $222.58 | $443.31 |