- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $111.25 / $111.25
| Professional | | $106.97 | $111.25 | $111.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Facility | | $106.97 | $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 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $111.25 / $111.25
| Professional | | $106.97 | $111.25 | $111.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $155.11
| Professional | | $106.97 | $106.97 | $155.11 |