- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.40 / $104.40 / $104.40
| Facility | | $104.40 | $104.40 | $104.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.40 / $104.40 / $104.40
| Professional | | $104.40 | $104.40 | $104.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.15 / $60.00 / $60.00
| Facility | | $54.15 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.22 / $112.22 / $112.22
| Professional | | $112.22 | $112.22 | $112.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.42 / $136.42 / $140.40
| Facility | | $136.42 | $136.42 | $140.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.40 / $140.40 / $140.40
| Professional | | $140.40 | $140.40 | $140.40 |