- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.49 / $1.73 / $2.29
| Professional | | $1.49 | $1.73 | $2.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.02 / $26.02 / $32.52
| Professional | | $26.02 | $26.02 | $32.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.27 / $17.27 / $17.27
| Facility | | $17.27 | $17.27 | $17.27 |