- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,843.17 / $3,843.17 / $3,843.17
| Professional | | $3,843.17 | $3,843.17 | $3,843.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,843.17 / $3,843.17 / $3,843.17
| Facility | | $3,843.17 | $3,843.17 | $3,843.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,843.17 / $3,843.17 / $3,843.17
| Professional | | $3,843.17 | $3,843.17 | $3,843.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $68.73 / $84.10
| Professional | | $68.73 | $68.73 | $84.10 |