- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,480.00 / $2,480.00
| Facility | | $2,480.00 | $2,480.00 | $2,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,480.00 / $2,480.00
| Professional | | $2,480.00 | $2,480.00 | $2,480.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.47 / $327.16 / $809.07
| Facility | | $138.47 | $327.16 | $809.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $173.10 / $408.94
| Professional | | $140.63 | $173.10 | $408.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,728.00 / $5,247.58
| Facility | | $2,480.00 | $2,728.00 | $5,247.58 |