- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $112.32
| Professional | | $112.32 | $112.32 | $112.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.96 / $200.94 / $334.89
| Facility | | $105.96 | $200.94 | $334.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $334.89
| Professional | | $112.32 | $112.32 | $334.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.96 / $200.94 / $334.89
| Facility | | $105.96 | $200.94 | $334.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $334.89
| Professional | | $112.32 | $112.32 | $334.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $336.96
| Professional | | $112.32 | $112.32 | $336.96 |