- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Facility | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.27 / $98.27 / $98.27
| Professional | | $98.27 | $98.27 | $98.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.23 / $126.75 / $134.41
| Facility | | $126.23 | $126.75 | $134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.48 / $126.11 / $126.11
| Professional | | $109.48 | $126.11 | $126.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.00 / $105.00 / $105.00
| Professional | | $105.00 | $105.00 | $105.00 |