- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $131.72
| Facility | | $131.72 | $131.72 | $131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $131.72 / $132.65
| Professional | | $106.45 | $131.72 | $132.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.76 / $56.76 / $56.76
| Professional | | $56.76 | $56.76 | $56.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $131.72
| Facility | | $131.72 | $131.72 | $131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $137.68
| Professional | | $131.72 | $131.72 | $137.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |