- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.72 / $104.72 / $104.72
| Facility | | $104.72 | $104.72 | $104.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.22 / $32.53 / $33.51
| Professional | | $32.22 | $32.53 | $33.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.55 / $31.55 / $56.92
| Facility | | $31.55 | $31.55 | $56.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.22 / $32.22 / $32.22
| Professional | | $32.22 | $32.22 | $32.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.39 / $32.22 / $32.22
| Facility | | $30.39 | $32.22 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.22 / $32.22 / $32.22
| Professional | | $32.22 | $32.22 | $32.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.66 / $32.22 / $32.22
| Professional | | $21.66 | $32.22 | $32.22 |