- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Facility | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Professional | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,111.53 / $4,805.00 / $18,925.00
| Professional | | $4,111.53 | $4,805.00 | $18,925.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Facility | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.73 / $3,152.42 / $4,111.53
| Professional | | $2,783.73 | $3,152.42 | $4,111.53 |