- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.00 / $307.00 / $307.00
| Facility | | $307.00 | $307.00 | $307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.00 / $2,017.00 / $2,017.00
| Professional | | $2,017.00 | $2,017.00 | $2,017.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.20 / $394.70 / $601.72
| Facility | | $257.20 | $394.70 | $601.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.02 / $2,343.02 / $2,343.02
| Professional | | $2,343.02 | $2,343.02 | $2,343.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |