- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.52 / $28.52 / $28.52
| Facility | | $28.52 | $28.52 | $28.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.68 / $28.52 / $41.51
| Professional | | $11.68 | $28.52 | $41.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.20 / $4.00 / $4.00
| Professional | | $3.20 | $4.00 | $4.00 |
- 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
- $1,426.43 / $1,426.43 / $1,426.43
| Professional | | $1,426.43 | $1,426.43 | $1,426.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |