- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.00 / $107.00 / $107.00
| Facility | | $107.00 | $107.00 | $107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.71 / $113.06 / $123.05
| Professional | | $106.71 | $113.06 | $123.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.96 / $124.41 / $239.46
| Professional | | $97.96 | $124.41 | $239.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $786.30 / $786.30 / $786.30
| Facility | | $786.30 | $786.30 | $786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.91 / $125.89 / $317.20
| Professional | | $77.91 | $125.89 | $317.20 |