- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.33 / $227.33 / $227.33
| Facility | | $227.33 | $227.33 | $227.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.33 / $227.33 / $230.00
| Professional | | $227.33 | $227.33 | $230.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.00 / $353.00 / $353.00
| Professional | | $353.00 | $353.00 | $353.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.22 / $238.70 / $279.62
| Facility | | $164.22 | $238.70 | $279.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.22 / $437.57 / $1,750.16
| Professional | | $164.22 | $437.57 | $1,750.16 |