- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.00 / $105.00 / $105.00
| Facility | | $105.00 | $105.00 | $105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.85 / $30.85 / $30.85
| Professional | | $30.85 | $30.85 | $30.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.13 / $130.13 / $130.13
| Professional | | $130.13 | $130.13 | $130.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.00 / $30.85 / $37.02
| Facility | | $8.00 | $30.85 | $37.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $8.00 / $8.00
| Professional | | $8.00 | $8.00 | $8.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |