- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $105.46
| Facility | | $105.46 | $105.46 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $106.77
| Professional | | $105.46 | $105.46 | $106.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.50 / $28.50 / $91.89
| Professional | | $28.50 | $28.50 | $91.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.61 / $47.61 / $73.80
| Facility | | $47.61 | $47.61 | $73.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.61 / $47.61 / $57.14
| Professional | | $47.61 | $47.61 | $57.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |