- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.73 / $107.06 / $133.82
| Professional | | $67.73 | $107.06 | $133.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.44 / $204.03 / $204.03
| Facility | | $85.44 | $204.03 | $204.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.00 / $108.00 / $108.00
| Professional | | $108.00 | $108.00 | $108.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.46 / $52.46 / $73.45
| Facility | | $52.46 | $52.46 | $73.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.45 / $98.00 / $125.65
| Professional | | $73.45 | $98.00 | $125.65 |