- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $5,011.87
| Facility | | $100.00 | $100.00 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $977.24
| Professional | | $758.58 | $891.25 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $891.25
| Facility | | $354.81 | $354.81 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $891.25
| Professional | | $794.33 | $891.25 | $891.25 |