- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- 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
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,545.58
| Facility | | $100.00 | $100.00 | $1,545.58 |