- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Facility | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Professional | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.39 / $30.00 / $30.00
| Professional | | $20.39 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $1,058.58 / $2,181.23
| Facility | | $973.77 | $1,058.58 | $2,181.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |