- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.43 / $102.85 / $145.19
| Facility | | $100.43 | $102.85 | $145.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.80 / $100.43 / $102.85
| Professional | | $96.80 | $100.43 | $102.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.24 / $102.85 / $102.85
| Facility | | $100.24 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $110.00
| Professional | | $102.85 | $102.85 | $110.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $102.85
| Facility | | $102.85 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $102.85
| Professional | | $102.85 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $110.00 / $126.50
| Professional | | $110.00 | $110.00 | $126.50 |