- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.63 / $101.63 / $101.63
| Facility | | $101.63 | $101.63 | $101.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $31.27 / $32.52
| Professional | | $31.27 | $31.27 | $32.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.33 / $31.33 / $36.75
| Facility | | $31.33 | $31.33 | $36.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $31.27 / $31.27
| Professional | | $31.27 | $31.27 | $31.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.50 / $31.27 / $31.27
| Facility | | $29.50 | $31.27 | $31.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $31.27 / $31.27
| Professional | | $31.27 | $31.27 | $31.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.27 / $31.27 / $31.27
| Professional | | $31.27 | $31.27 | $31.27 |