- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,570.00 / $3,570.00 / $3,570.00
| Facility | | $3,570.00 | $3,570.00 | $3,570.00 |
- 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
- $3,536.34 / $4,297.00 / $16,277.00
| Professional | | $3,536.34 | $4,297.00 | $16,277.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,570.00 / $3,570.00 / $3,570.00
| Facility | | $3,570.00 | $3,570.00 | $3,570.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,394.31 / $2,711.42 / $3,536.34
| Professional | | $2,394.31 | $2,711.42 | $3,536.34 |