- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,736.54 / $2,736.54 / $2,736.54
| Facility | | $2,736.54 | $2,736.54 | $2,736.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $2,736.54 / $2,736.54
| Professional | | $2,736.53 | $2,736.54 | $2,736.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $3,344.98 / $8,118.75
| Professional | | $200.00 | $3,344.98 | $8,118.75 |
- 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
- $2,571.89 / $2,899.80 / $5,512.33
| Professional | | $2,571.89 | $2,899.80 | $5,512.33 |