- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,947.82 / $2,947.82 / $2,947.82
| Facility | | $2,947.82 | $2,947.82 | $2,947.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $2,947.82 / $2,947.82
| Professional | | $2,947.82 | $2,947.82 | $2,947.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Facility | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $479.92 / $6,708.75
| Professional | | $422.50 | $479.92 | $6,708.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.59 / $3,122.29 / $5,644.87
| Professional | | $2,872.59 | $3,122.29 | $5,644.87 |