- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $132.77
| Facility | | $119.61 | $119.61 | $132.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $132.77
| Professional | | $119.61 | $119.61 | $132.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.36 / $131.35 / $131.35
| Facility | | $52.36 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Professional | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.28 / $130.30 / $140.74
| Professional | | $117.28 | $130.30 | $140.74 |