- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.38 / $210.38 / $210.38
| Professional | | $210.38 | $210.38 | $210.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.00 / $360.00 / $360.00
| Facility | | $360.00 | $360.00 | $360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $360.00 / $360.00
| Professional | | $360.00 | $360.00 | $360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $220.00 / $400.00
| Professional | | $220.00 | $220.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.34 / $212.77 / $253.18
| Professional | | $170.34 | $212.77 | $253.18 |