- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $107.15 / $107.15
| Facility | | $100.00 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $42.66 / $52.48
| Professional | | $33.11 | $42.66 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Facility | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $53.70
| Professional | | $44.67 | $44.67 | $53.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $107.15
| Facility | | $100.00 | $100.00 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $44.67 / $107.15
| Professional | | $33.11 | $44.67 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $43.65 / $63.10
| Professional | | $32.36 | $43.65 | $63.10 |