- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.81 / $113.81 / $113.81
| Facility | | $113.81 | $113.81 | $113.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $113.81
| Professional | | $109.44 | $109.44 | $113.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.24 / $109.44 / $109.44
| Facility | | $103.24 | $109.44 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Professional | | $109.44 | $109.44 | $109.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.44 / $109.44 / $109.44
| Professional | | $109.44 | $109.44 | $109.44 |