- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.45 / $112.44 / $112.44
| Professional | | $87.45 | $112.44 | $112.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $120.00 / $120.00
| Facility | | $120.00 | $120.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $120.00 / $152.31
| Professional | | $102.00 | $120.00 | $152.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $120.00 / $120.00
| Facility | | $120.00 | $120.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $120.00 / $152.31
| Professional | | $102.00 | $120.00 | $152.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.42 / $106.19 / $192.18
| Professional | | $50.42 | $106.19 | $192.18 |