- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $1,987.50
| Facility | | $1,987.50 | $1,987.50 | $1,987.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $2,252.50
| Professional | | $1,987.50 | $1,987.50 | $2,252.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.50 / $2,097.00 / $3,500.00
| Facility | | $1,987.50 | $2,097.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,637.50 / $4,637.50 / $4,637.50
| Professional | | $4,637.50 | $4,637.50 | $4,637.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |