- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,133.39 / $6,850.00 / $6,850.00
| Professional | | $5,133.39 | $6,850.00 | $6,850.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.94 / $153.94 / $192.44
| Facility | | $153.94 | $153.94 | $192.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.03 / $4,002.70 / $6,654.50
| Professional | | $3,002.03 | $4,002.70 | $6,654.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $6,850.00
| Facility | | $5,133.39 | $5,133.39 | $6,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $5,133.39
| Professional | | $5,133.39 | $5,133.39 | $5,133.39 |