- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,160.84 / $5,160.84 / $5,160.84
| Professional | | $5,160.84 | $5,160.84 | $5,160.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.95 / $1.00 / $1.00
| Facility | | $0.95 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Professional | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.91 / $3,467.91 / $3,467.91
| Professional | | $3,467.91 | $3,467.91 | $3,467.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $5,160.84
| Facility | | $100.00 | $100.00 | $5,160.84 |