- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,390.40 / $2,390.40 / $2,390.40
| Facility | | $2,390.40 | $2,390.40 | $2,390.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.80 / $2,390.40 / $2,476.80
| Professional | | $2,332.80 | $2,390.40 | $2,476.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $396.00 / $396.00
| Professional | | $396.00 | $396.00 | $396.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $2,400.00
| Professional | | $2,400.00 | $2,400.00 | $2,400.00 |