- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.00 / $3,570.00 / $3,570.00
| Professional | | $3,570.00 | $3,570.00 | $3,570.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,082.91 / $15,082.91 / $15,082.91
| Facility | | $15,082.91 | $15,082.91 | $15,082.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,082.91 / $15,082.91 / $15,082.91
| Professional | | $15,082.91 | $15,082.91 | $15,082.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,220.00 / $3,220.00 / $3,220.00
| Facility | | $3,220.00 | $3,220.00 | $3,220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,842.77 / $2,921.26 / $3,486.03
| Professional | | $2,842.77 | $2,921.26 | $3,486.03 |