- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $104.77
| Facility | | $101.72 | $101.72 | $104.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $109.85
| Professional | | $101.72 | $101.72 | $109.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $109.30 / $158.13
| Facility | | $101.72 | $109.30 | $158.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $107.47
| Professional | | $101.72 | $101.72 | $107.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.66 / $101.72 / $101.72
| Facility | | $96.66 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $110.35
| Professional | | $101.72 | $101.72 | $110.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $124.10
| Professional | | $101.72 | $101.72 | $124.10 |