- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.56 / $162.56 / $162.56
| Facility | | $162.56 | $162.56 | $162.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $171.20
| Facility | | $1.21 | $1.21 | $171.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $26.85
| Professional | | $21.48 | $21.48 | $26.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.21 / $1.21 / $171.20
| Facility | | $1.21 | $1.21 | $171.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $26.85 / $27.50
| Professional | | $21.48 | $26.85 | $27.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.55 / $14.62 / $32.18
| Professional | | $12.55 | $14.62 | $32.18 |