- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $107.15 / $177.83
| Facility | | $100.00 | $107.15 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.20 / $112.20 / $112.20
| Facility | | $1.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $19.50
| Professional | | $15.85 | $15.85 | $19.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.32 / $8.32 / $8.32
| Facility | | $8.32 | $8.32 | $8.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $15.14 / $33.88
| Professional | | $9.12 | $15.14 | $33.88 |