- 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
- $4,400.00 / $5,500.00 / $6,934.05
| Professional | | $4,400.00 | $5,500.00 | $6,934.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,133.39 / $5,133.39 / $6,365.42
| Facility | | $5,133.39 | $5,133.39 | $6,365.42 |
- 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
- $30.00 / $1,610.32 / $3,491.16
| Professional | | $30.00 | $1,610.32 | $3,491.16 |