- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $6,096.84
| Professional | | $648.63 | $3,087.00 | $6,096.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $5,813.76 / $7,356.80
| Facility | | $3,087.00 | $5,813.76 | $7,356.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $6,096.84
| Professional | | $648.63 | $3,087.00 | $6,096.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.98 / $2,594.52 / $4,324.20
| Professional | | $2,344.98 | $2,594.52 | $4,324.20 |