- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $1,995.26
| Professional | | $234.42 | $234.42 | $1,995.26 |
- 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
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $234.42 / $1,202.26
| Facility | | $100.00 | $234.42 | $1,202.26 |