- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,000.45 / $4,000.45 / $4,000.45
| Facility | | $4,000.45 | $4,000.45 | $4,000.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.86 / $4,000.45 / $4,145.05
| Professional | | $3,855.86 | $4,000.45 | $4,145.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,819.82 / $4,819.82 / $4,819.82
| Professional | | $4,819.82 | $4,819.82 | $4,819.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $60.00 / $60.00
| Professional | | $30.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,684.00 / $5,684.00 / $5,684.00
| Professional | | $5,684.00 | $5,684.00 | $5,684.00 |