- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.72 / $102.73 / $104.77
| Facility | | $101.72 | $102.73 | $104.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $102.73 / $122.06
| Professional | | $101.72 | $102.73 | $122.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.40 / $112.40 / $168.60
| Facility | | $112.40 | $112.40 | $168.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.40 / $112.40 / $114.65
| Professional | | $112.40 | $112.40 | $114.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.96 / $95.96 / $101.72
| Facility | | $95.96 | $95.96 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.72 / $101.72 / $101.72
| Professional | | $101.72 | $101.72 | $101.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.65 / $101.72 / $124.10
| Professional | | $96.65 | $101.72 | $124.10 |