- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.11 / $130.11 / $130.11
| Facility | | $130.11 | $130.11 | $130.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $119.29 / $120.38
| Professional | | $109.44 | $119.29 | $120.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.80 / $1,668.00 / $1,668.00
| Professional | | $1,417.80 | $1,668.00 | $1,668.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.24 / $103.24 / $103.24
| Facility | | $103.24 | $103.24 | $103.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $154.86 / $154.86
| Professional | | $109.44 | $154.86 | $154.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Professional | | $109.44 | $109.44 | $109.44 |