- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,932.50 / $6,932.50 / $6,932.50
| Professional | | $6,932.50 | $6,932.50 | $6,932.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.90 / $207.90 / $259.88
| Facility | | $207.90 | $207.90 | $259.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,054.13 / $5,405.50 / $8,986.65
| Professional | | $4,054.13 | $5,405.50 | $8,986.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,932.50 / $6,932.50 / $6,932.50
| Facility | | $6,932.50 | $6,932.50 | $6,932.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,932.50 / $6,932.50 / $6,932.50
| Professional | | $6,932.50 | $6,932.50 | $6,932.50 |