- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.06 / $116.06 / $116.06
| Facility | | $116.06 | $116.06 | $116.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.06 / $116.06 / $116.06
| Professional | | $116.06 | $116.06 | $116.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.00 / $122.02 / $148.85
| Professional | | $117.00 | $122.02 | $148.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $102.82 / $102.82
| Professional | | $102.82 | $102.82 | $102.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.53 / $141.53 / $432.23
| Professional | | $141.53 | $141.53 | $432.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.42 / $108.63 / $153.88
| Professional | | $72.42 | $108.63 | $153.88 |