- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $120.23
| Professional | | $104.71 | $104.71 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $128.82 / $128.82
| Professional | | $109.65 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $117.49 / $147.91
| Professional | | $104.71 | $117.49 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $194.98
| Facility | | $100.00 | $100.00 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $104.71 / $112.20
| Professional | | $97.72 | $104.71 | $112.20 |