- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.33 / $28.33 / $28.33
| Professional | | $28.33 | $28.33 | $28.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $70.00 / $1,500.00
| Professional | | $32.34 | $70.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Facility | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.36 / $1.41 / $2,250,000.00
| Professional | | $1.36 | $1.41 | $2,250,000.00 |