- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $35.00 / $35.00
| Professional | | $35.00 | $35.00 | $35.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.28 / $20.53 / $30.00
| Professional | | $15.28 | $20.53 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.61 / $55.61 / $55.61
| Professional | | $55.61 | $55.61 | $55.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $35.00 / $35.00
| Professional | | $35.00 | $35.00 | $35.00 |