- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.07 / $105.07 / $105.07
| Facility | | $105.07 | $105.07 | $105.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $105.07
| Professional | | $101.03 | $101.03 | $105.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.59 / $204.75 / $252.03
| Facility | | $111.59 | $204.75 | $252.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.85 / $111.59 / $111.59
| Professional | | $94.85 | $111.59 | $111.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.31 / $101.03 / $101.03
| Facility | | $95.31 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |