- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.67 / $64.75 / $76.20
| Professional | | $59.67 | $64.75 | $76.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.00 / $126.00 / $128.85
| Facility | | $126.00 | $126.00 | $128.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.52 / $109.52 / $128.85
| Professional | | $109.52 | $109.52 | $128.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.49 / $101.49 / $101.49
| Professional | | $101.49 | $101.49 | $101.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.31 / $77.83 / $110.69
| Professional | | $65.31 | $77.83 | $110.69 |