- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.00 / $95.00 / $183.35
| Facility | | $95.00 | $95.00 | $183.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.30 / $95.00 / $95.00
| Professional | | $47.30 | $95.00 | $95.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.76 / $102.76 / $152.56
| Facility | | $102.76 | $102.76 | $152.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.37 / $111.37 / $111.37
| Professional | | $111.37 | $111.37 | $111.37 |