- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $105.07 / $108.34
| Professional | | $101.03 | $105.07 | $108.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.86 / $112.32 / $320.16
| Facility | | $89.86 | $112.32 | $320.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Facility | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $105.07 / $108.34
| Professional | | $101.03 | $105.07 | $108.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $146.49
| Professional | | $101.03 | $101.03 | $146.49 |