- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.78 / $24.55 / $41.69
| Facility | | $17.78 | $24.55 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $15.85 / $23.99
| Professional | | $5.62 | $15.85 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.78 / $23.44 / $27.54
| Professional | | $17.78 | $23.44 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $33.11
| Professional | | $30.20 | $30.20 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $17.38 / $48.98
| Professional | | $11.22 | $17.38 | $48.98 |