- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,840.00 / $11,983.98 / $23,152.50
| Professional | | $6,840.00 | $11,983.98 | $23,152.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $85.00
| Professional | | $50.00 | $58.40 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,900.00 / $5,900.00 / $5,900.00
| Professional | | $5,900.00 | $5,900.00 | $5,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $100.00
| Facility | | $65.00 | $65.00 | $100.00 |