- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,386.40 / $3,386.40 / $3,386.40
| Facility | | $3,386.40 | $3,386.40 | $3,386.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,386.40 / $3,386.40 / $3,725.04
| Professional | | $3,386.40 | $3,386.40 | $3,725.04 |
- 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
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,876.00 / $4,069.80 / $5,027.17
| Professional | | $3,876.00 | $4,069.80 | $5,027.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,400.00 / $3,400.00 / $3,400.00
| Professional | | $3,400.00 | $3,400.00 | $3,400.00 |