- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.38 / $100.38 / $102.80
| Facility | | $100.38 | $100.38 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $100.38 / $102.80
| Professional | | $96.75 | $100.38 | $102.80 |
- 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
- $102.80 / $102.80 / $102.80
| Facility | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.80 / $102.80 / $102.80
| Professional | | $102.80 | $102.80 | $102.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.80 / $127.38 / $222.92
| Professional | | $102.80 | $127.38 | $222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $191.07
| Professional | | $127.38 | $127.38 | $191.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.78 / $100.78 / $100.78
| Professional | | $100.78 | $100.78 | $100.78 |