- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.11 / $110.11 / $110.11
| Facility | | $110.11 | $110.11 | $110.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $34.22 / $2,260.32
| Professional | | $33.88 | $34.22 | $2,260.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.47 / $34.47 / $39.90
| Facility | | $34.47 | $34.47 | $39.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Facility | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |