- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $177.83 / $302.00
| Facility | | $104.71 | $177.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $144.54
| Professional | | $104.71 | $104.71 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $144.54 / $288.40
| Facility | | $109.65 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $144.54
| Professional | | $104.71 | $104.71 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $104.71 / $151.36
| Facility | | $97.72 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $107.15 / $134.90
| Professional | | $104.71 | $107.15 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $181.97
| Facility | | $100.00 | $104.71 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $128.82
| Professional | | $104.71 | $104.71 | $128.82 |