- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.08 / $106.08 / $121.24
| Facility | | $106.08 | $106.08 | $121.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $106.08 / $121.24
| Professional | | $101.03 | $106.08 | $121.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.30 / $79.30 / $87.23
| Facility | | $79.30 | $79.30 | $87.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.96 / $120.96
| Professional | | $109.65 | $120.96 | $120.96 |
- 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 / $108.34
| Professional | | $101.03 | $101.03 | $108.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.98 / $101.03 / $131.34
| Professional | | $95.98 | $101.03 | $131.34 |