- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $10,000.00
| Facility | | $199.53 | $199.53 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Facility | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.98 / $1.00 / $1.00
| Professional | | $0.98 | $1.00 | $1.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $5,128.61
| Facility | | $100.00 | $100.00 | $5,128.61 |