- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.82 / $104.82 / $125.58
| Professional | | $104.82 | $104.82 | $125.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.94 / $130.90 / $134.82
| Facility | | $91.94 | $130.90 | $134.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.41 / $130.41 / $130.41
| Professional | | $130.41 | $130.41 | $130.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.41 / $130.90 / $138.85
| Facility | | $94.41 | $130.90 | $138.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.41 / $130.41 / $130.41
| Professional | | $130.41 | $130.41 | $130.41 |