- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $2.00
| Professional | | $1.00 | $1.00 | $2.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.32 / $1.45 / $14.13
| Facility | | $1.32 | $1.45 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $60.26
| Professional | | $1.00 | $1.00 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.32 / $1.58 / $14.13
| Facility | | $1.32 | $1.58 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $3.31 / $3.31
| Professional | | $3.31 | $3.31 | $3.31 |