- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.14 / $100.79 / $116.92
| Facility | | $97.14 | $100.79 | $116.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.14 / $100.79 / $103.22
| Professional | | $97.14 | $100.79 | $103.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.82 / $11.82 / $11.82
| Professional | | $11.82 | $11.82 | $11.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $103.22 / $103.22
| Facility | | $103.22 | $103.22 | $103.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.19 / $101.19 / $107.26
| Professional | | $101.19 | $101.19 | $107.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.72 / $98.72 / $98.72
| Professional | | $98.72 | $98.72 | $98.72 |