- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,388.46 / $8,388.46 / $8,388.46
| Facility | | $8,388.46 | $8,388.46 | $8,388.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.00 / $3,264.00 / $3,264.00
| Professional | | $3,264.00 | $3,264.00 | $3,264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.00 / $3,264.00 / $3,264.00
| Professional | | $3,264.00 | $3,264.00 | $3,264.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,620.36 / $15,620.36 / $15,620.36
| Facility | | $15,620.36 | $15,620.36 | $15,620.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.00 / $3,200.00 / $4,800.00
| Professional | | $3,200.00 | $3,200.00 | $4,800.00 |