- 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
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.03
| Professional | | $0.02 | $0.02 | $0.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.51 / $66.51 / $81.30
| Facility | | $66.51 | $66.51 | $81.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $60.00
| Professional | | $30.00 | $50.00 | $60.00 |