- 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 / $151.54
| Professional | | $101.03 | $101.03 | $151.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.11 / $102.49 / $110.98
| Professional | | $91.11 | $102.49 | $110.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.09 / $168.09 / $193.30
| Facility | | $168.09 | $168.09 | $193.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.44 / $108.51 / $134.30
| Professional | | $107.44 | $108.51 | $134.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.54 / $123.33 / $181.85
| Facility | | $98.54 | $123.33 | $181.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.54 / $98.54 / $110.36
| Professional | | $98.54 | $98.54 | $110.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $109.72
| Professional | | $101.03 | $101.03 | $109.72 |