- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Facility | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.00 / $1,310.00 / $3,006.86
| Facility | | $926.00 | $1,310.00 | $3,006.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.50 / $233.50 / $256.85
| Professional | | $233.50 | $233.50 | $256.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.78 / $1,002.90 / $1,002.90
| Professional | | $979.78 | $1,002.90 | $1,002.90 |