- 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
- $40.72 / $96.20 / $237.91
| Facility | | $40.72 | $96.20 | $237.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.27 / $135.72 / $320.64
| Professional | | $110.27 | $135.72 | $320.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.37 / $111.37 / $111.37
| Professional | | $111.37 | $111.37 | $111.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $106.00 / $203.00
| Facility | | $100.00 | $106.00 | $203.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |