- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $154.06
| Professional | | $120.36 | $120.36 | $154.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.28 / $113.28 / $113.28
| Professional | | $113.28 | $113.28 | $113.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.44 / $127.44 / $127.44
| Professional | | $127.44 | $127.44 | $127.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $125.08
| Professional | | $118.00 | $118.00 | $125.08 |