- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $5,133.39
| Facility | | $5,133.39 | $5,133.39 | $5,133.39 |
- 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 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.86 / $5,793.86 / $5,793.86
| Professional | | $5,793.86 | $5,793.86 | $5,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.20 / $5,133.39 / $5,133.39
| Facility | | $300.20 | $5,133.39 | $5,133.39 |
- 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 |