- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $53.00
| Professional | | $53.00 | $53.00 | $53.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $112.20 / $187.00
| Facility | | $50.00 | $112.20 | $187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $187.00
| Professional | | $53.00 | $53.00 | $187.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $112.20 / $187.00
| Facility | | $50.00 | $112.20 | $187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $187.00
| Professional | | $53.00 | $53.00 | $187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $159.00
| Professional | | $53.00 | $53.00 | $159.00 |