- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $105.78 / $105.78
| Professional | | $101.72 | $105.78 | $105.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Facility | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $105.78 / $105.78
| Professional | | $101.72 | $105.78 | $105.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $147.49
| Professional | | $101.72 | $101.72 | $147.49 |