- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $553.00
| Facility | | $100.00 | $100.00 | $553.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.00 / $53.62 / $95.00
| Professional | | $43.00 | $53.62 | $95.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.37 / $111.37 / $111.37
| Professional | | $111.37 | $111.37 | $111.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.37 / $111.37 / $111.37
| Professional | | $111.37 | $111.37 | $111.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |