- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $3,468.00
| Facility | | $3,468.00 | $3,468.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,386.40 / $3,386.40 / $3,468.00
| Professional | | $3,386.40 | $3,386.40 | $3,468.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $3,468.00
| Facility | | $3,468.00 | $3,468.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $3,468.00
| Professional | | $3,468.00 | $3,468.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,240.20 / $3,400.00 / $4,080.00
| Professional | | $3,240.20 | $3,400.00 | $4,080.00 |