- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.30 / $104.30 / $104.30
| Facility | | $104.30 | $104.30 | $104.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.84 / $101.84 / $104.30
| Professional | | $101.84 | $101.84 | $104.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.48 / $112.48 / $112.48
| Facility | | $112.48 | $112.48 | $112.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.48 / $112.48 / $112.48
| Professional | | $112.48 | $112.48 | $112.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $112.48
| Facility | | $108.39 | $108.39 | $112.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.43 / $122.70 / $122.70
| Professional | | $110.43 | $122.70 | $122.70 |