- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,675.77 / $5,675.77 / $33,409.85
| Facility | | $5,675.77 | $5,675.77 | $33,409.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,540.62 / $5,675.77 / $5,675.77
| Professional | | $4,540.62 | $5,675.77 | $5,675.77 |
- 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
- $540.54 / $540.54 / $599.47
| Professional | | $540.54 | $540.54 | $599.47 |