- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.98 / $2,062.98 / $2,062.98
| Facility | | $2,062.98 | $2,062.98 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.98 / $2,062.98 / $2,062.98
| Professional | | $2,062.98 | $2,062.98 | $2,062.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- 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
- $143.24 / $256.69 / $3,025.68
| Professional | | $143.24 | $256.69 | $3,025.68 |