- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.75 / $96.75 / $96.75
| Facility | | $96.75 | $96.75 | $96.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $100.38 / $120.94
| Professional | | $96.75 | $100.38 | $120.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.96 / $98.94 / $107.14
| Professional | | $87.96 | $98.94 | $107.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Professional | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.75 / $108.85 / $164.48
| Facility | | $96.75 | $108.85 | $164.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $112.87
| Professional | | $100.78 | $100.78 | $112.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $112.87
| Professional | | $100.78 | $100.78 | $112.87 |