- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.80 / $106.80 / $122.06
| Facility | | $106.80 | $106.80 | $122.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $106.80 / $122.06
| Professional | | $101.72 | $106.80 | $122.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $171.00 / $171.00
| Professional | | $171.00 | $171.00 | $171.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Facility | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.63 / $101.72 / $132.24
| Professional | | $96.63 | $101.72 | $132.24 |