- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Facility | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $127.60
| Professional | | $106.33 | $106.33 | $127.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.04 / $136.04 / $136.04
| Professional | | $136.04 | $136.04 | $136.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.57 / $459.72 / $7,637.32
| Facility | | $196.57 | $459.72 | $7,637.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Facility | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $106.33 / $106.33
| Professional | | $106.33 | $106.33 | $106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.38 / $106.33 / $116.96
| Professional | | $90.38 | $106.33 | $116.96 |