- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,505.00 / $6,505.00 / $6,505.00
| Facility | | $6,505.00 | $6,505.00 | $6,505.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $5,120.10
| Professional | | $5,120.10 | $5,120.10 | $5,120.10 |
- 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
- $186.01 / $347.56 / $540.20
| Professional | | $186.01 | $347.56 | $540.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $5,120.10
| Facility | | $100.00 | $100.00 | $5,120.10 |