- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.60 / $1,114.60 / $1,114.60
| Facility | | $1,114.60 | $1,114.60 | $1,114.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.60 / $1,114.60 / $1,114.60
| Professional | | $1,114.60 | $1,114.60 | $1,114.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $5,170.31
| Professional | | $287.76 | $2,837.98 | $5,170.31 |
- 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
- $1,047.61 / $1,713.46 / $2,245.23
| Professional | | $1,047.61 | $1,713.46 | $2,245.23 |