- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.32 / $96.32 / $96.32
| Professional | | $96.32 | $96.32 | $96.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.45 / $121.45 / $121.45
| Facility | | $121.45 | $121.45 | $121.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.23 / $120.29 / $121.45
| Professional | | $96.23 | $120.29 | $121.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.45 / $121.45 / $121.45
| Facility | | $121.45 | $121.45 | $121.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.38 / $83.76 / $104.70
| Professional | | $75.38 | $83.76 | $104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.18 / $35.18 / $83.76
| Professional | | $35.18 | $35.18 | $83.76 |