- 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
- $225.32 / $225.32 / $447.17
| Professional | | $225.32 | $225.32 | $447.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.76 / $250.06 / $532.39
| Professional | | $150.76 | $250.06 | $532.39 |