- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $242.71
| Facility | | $242.71 | $242.71 | $242.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $400.00
| Professional | | $242.71 | $242.71 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $298.52
| Facility | | $242.71 | $242.71 | $298.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.20 / $290.20 / $290.20
| Professional | | $290.20 | $290.20 | $290.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.70 / $57.70 / $57.70
| Professional | | $57.70 | $57.70 | $57.70 |