- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $160.91
| Facility | | $102.85 | $102.85 | $160.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.01 / $102.85 / $102.85
| Professional | | $98.01 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.85 / $110.00 / $110.00
| Professional | | $102.85 | $110.00 | $110.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $102.85
| Facility | | $102.85 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $102.85
| Professional | | $102.85 | $102.85 | $102.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.85 / $102.85 / $108.90
| Professional | | $102.85 | $102.85 | $108.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.50 / $110.00 / $115.50
| Professional | | $104.50 | $110.00 | $115.50 |