- 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 / $83.40
| Professional | | $30.00 | $30.00 | $83.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.11 / $2,780.91 / $3,006.86
| Facility | | $2,607.11 | $2,780.91 | $3,006.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.50 / $233.50 / $233.50
| Professional | | $233.50 | $233.50 | $233.50 |