- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.03 / $86.03 / $99.27
| Professional | | $86.03 | $86.03 | $99.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.16 / $110.16 / $129.58
| Facility | | $110.16 | $110.16 | $129.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.42 / $110.16 / $113.46
| Professional | | $80.42 | $110.16 | $113.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.16 / $110.16 / $129.58
| Facility | | $110.16 | $110.16 | $129.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.42 / $110.16 / $113.46
| Professional | | $80.42 | $110.16 | $113.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.64 / $104.43 / $203.81
| Professional | | $58.64 | $104.43 | $203.81 |