- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.38 / $54.38 / $67.97
| Professional | | $54.38 | $54.38 | $67.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $102.00
| Facility | | $102.00 | $102.00 | $102.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $105.54 / $190.43
| Professional | | $102.00 | $105.54 | $190.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.00 / $128.66 / $128.66
| Facility | | $102.00 | $128.66 | $128.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.07 / $106.60 / $192.19
| Professional | | $96.07 | $106.60 | $192.19 |