- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.50 / $119.50 / $119.50
| Facility | | $119.50 | $119.50 | $119.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $36.77 / $38.24
| Professional | | $36.77 | $36.77 | $38.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.74 / $36.74 / $39.22
| Facility | | $36.74 | $36.74 | $39.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $36.77 / $36.77
| Professional | | $36.77 | $36.77 | $36.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.68 / $36.77 / $36.77
| Facility | | $34.68 | $36.77 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $36.77 / $36.77
| Professional | | $36.77 | $36.77 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $36.77 / $36.77
| Professional | | $36.77 | $36.77 | $36.77 |