- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Professional | | $240.00 | $240.00 | $240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.00 / $307.20 / $439.20
| Facility | | $240.00 | $307.20 | $439.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $78.00
| Professional | | $30.00 | $30.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,700.00 / $15,298.00 / $26,104.00
| Facility | | $3,700.00 | $15,298.00 | $26,104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.72 / $333.35 / $519.58
| Professional | | $202.72 | $333.35 | $519.58 |