- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.32 / $112.32 / $128.36
| Facility | | $112.32 | $112.32 | $128.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $112.32 / $128.36
| Professional | | $106.97 | $112.32 | $128.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $5.32 / $5.32
| Professional | | $5.32 | $5.32 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Facility | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $50.00
| Professional | | $17.00 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.62 / $106.97 / $139.06
| Professional | | $101.62 | $106.97 | $139.06 |