- 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
- $1.00 / $1.00 / $3,174.75
| Facility | | $1.00 | $1.00 | $3,174.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.20 / $2,053.01 / $2,116.50
| Professional | | $1,693.20 | $2,053.01 | $2,116.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $2,480.00
| Facility | | $100.00 | $100.00 | $2,480.00 |