- 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
- Professional
- Modifier
- Low / Median / High Price
- $15,161.00 / $18,820.00 / $18,820.00
| Professional | | $15,161.00 | $18,820.00 | $18,820.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,748.50 / $3,748.50 / $3,748.50
| Facility | | $3,748.50 | $3,748.50 | $3,748.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.72 / $2,675.72 / $3,789.48
| Professional | | $2,675.72 | $2,675.72 | $3,789.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.72 / $2,675.72 / $3,789.48
| Professional | | $2,675.72 | $2,675.72 | $3,789.48 |