- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.41 / $222.41 / $222.41
| Facility | | $222.41 | $222.41 | $222.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.41 / $222.41 / $225.02
| Professional | | $222.41 | $222.41 | $225.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.00 / $272.00 / $272.00
| Professional | | $272.00 | $272.00 | $272.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.41 / $236.27 / $400.08
| Facility | | $222.41 | $236.27 | $400.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.64 / $430.01 / $1,712.50
| Professional | | $234.64 | $430.01 | $1,712.50 |