- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.05 / $77.05 / $77.05
| Professional | | $77.05 | $77.05 | $77.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $104.00 / $104.00
| Facility | | $104.00 | $104.00 | $104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.45 / $71.45 / $89.31
| Professional | | $71.45 | $71.45 | $89.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $104.00 / $104.00
| Facility | | $104.00 | $104.00 | $104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.39 / $71.45 / $89.31
| Professional | | $40.39 | $71.45 | $89.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.60 / $37.28 / $87.00
| Professional | | $33.60 | $37.28 | $87.00 |