- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $108.04
| Facility | | $106.97 | $106.97 | $108.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $112.32
| Professional | | $106.97 | $106.97 | $112.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $127.12
| Facility | | $106.97 | $106.97 | $127.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $108.03
| Professional | | $106.97 | $106.97 | $108.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.91 / $106.97 / $106.97
| Facility | | $100.91 | $106.97 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $117.67
| Professional | | $106.97 | $106.97 | $117.67 |