- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.84 / $119.63 / $230.43
| Facility | | $101.84 | $119.63 | $230.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $101.84 / $104.30
| Professional | | $100.00 | $101.84 | $104.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $0.03 / $0.07
| Facility | | $0.02 | $0.03 | $0.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.84 / $108.39 / $108.39
| Professional | | $101.84 | $108.39 | $108.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Facility | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.70 / $122.70 / $126.38
| Professional | | $122.70 | $122.70 | $126.38 |