- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.78 / $93.78 / $108.21
| Professional | | $93.78 | $93.78 | $108.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $141.25
| Facility | | $124.31 | $124.31 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.75 / $90.75 / $119.63
| Professional | | $90.75 | $90.75 | $119.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $141.25
| Facility | | $124.31 | $124.31 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.75 / $90.75 / $119.63
| Professional | | $90.75 | $90.75 | $119.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.92 / $121.65 / $222.16
| Professional | | $63.92 | $121.65 | $222.16 |