- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.20 / $114.82 / $114.82
| Facility | | $1.20 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $16.60 / $20.42
| Professional | | $16.60 | $16.60 | $20.42 |
- 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
- $10.72 / $15.14 / $51.29
| Professional | | $10.72 | $15.14 | $51.29 |