- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $115.60 / $115.60
| Professional | | $111.15 | $115.60 | $115.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $122.26
| Professional | | $111.15 | $111.15 | $122.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Facility | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $111.15
| Professional | | $111.15 | $111.15 | $111.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $115.60 / $115.60
| Professional | | $111.15 | $115.60 | $115.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $161.16
| Professional | | $111.15 | $111.15 | $161.16 |