- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $8,500.00
| Facility | | $367.50 | $367.50 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $367.50
| Professional | | $367.50 | $367.50 | $367.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.05 / $751.53 / $970.49
| Professional | | $464.05 | $751.53 | $970.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.50 / $367.50 / $1,102.50
| Facility | | $367.50 | $367.50 | $1,102.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.96 / $3,548.96 / $3,548.96
| Facility | | $3,548.96 | $3,548.96 | $3,548.96 |