- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $102.33 / $102.33
| Facility | | $97.72 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $100.00 / $102.33
| Professional | | $97.72 | $100.00 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $89.13 / $107.15
| Professional | | $89.13 | $89.13 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $102.33 / $117.49
| Facility | | $97.72 | $102.33 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $22.91 / $30.20
| Facility | | $22.91 | $22.91 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $131.83
| Professional | | $102.33 | $102.33 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |