- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.62 / $84.62 / $97.64
| Professional | | $84.62 | $84.62 | $97.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.46 / $144.01 / $144.01
| Facility | | $127.46 | $144.01 | $144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $137.32 / $148.33
| Professional | | $105.13 | $137.32 | $148.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.46 / $144.01 / $144.01
| Facility | | $127.46 | $144.01 | $144.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.13 / $144.00 / $148.33
| Professional | | $105.13 | $144.00 | $148.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.98 / $102.72 / $200.47
| Professional | | $59.98 | $102.72 | $200.47 |