- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.61 / $105.33 / $110.60
| Facility | | $79.61 | $105.33 | $110.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Professional | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Facility | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $105.33 / $114.35
| Professional | | $91.48 | $105.33 | $114.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.26 / $52.67 / $158.00
| Professional | | $44.26 | $52.67 | $158.00 |