- 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
- $4,770.67 / $5,247.73 / $5,612.55
| Professional | | $4,770.67 | $5,247.73 | $5,612.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,740.00 / $16,740.00 / $16,740.00
| Facility | | $16,740.00 | $16,740.00 | $16,740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,740.00 / $16,740.00 / $16,740.00
| Professional | | $16,740.00 | $16,740.00 | $16,740.00 |
- 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 |