- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.60 / $9.60 / $10.94
| Professional | | $9.60 | $9.60 | $10.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,603.60 / $4,622.80 / $8,200.00
| Facility | | $3,603.60 | $4,622.80 | $8,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.97 / $35.34 / $125.00
| Professional | | $23.97 | $35.34 | $125.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.75 / $17.64 / $18.89
| Professional | | $15.75 | $17.64 | $18.89 |