- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.36 / $212.36 / $212.36
| Facility | | $212.36 | $212.36 | $212.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.36 / $212.36 / $213.84
| Professional | | $212.36 | $212.36 | $213.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.55 / $243.00 / $243.00
| Professional | | $206.55 | $243.00 | $243.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.74 / $201.74 / $201.74
| Facility | | $201.74 | $201.74 | $201.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $213.84 / $302.61
| Professional | | $213.84 | $213.84 | $302.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $213.84 / $213.84
| Professional | | $213.84 | $213.84 | $213.84 |