- 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 / $3,465.19
| Professional | | $1,987.50 | $1,987.50 | $3,465.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.38 / $557.20 / $2,262.62
| Professional | | $520.38 | $557.20 | $2,262.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,344.96 / $3,557.63 / $6,930.38
| Facility | | $3,344.96 | $3,557.63 | $6,930.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.62 / $2,262.62 / $2,262.62
| Facility | | $2,262.62 | $2,262.62 | $2,262.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.63 / $2,262.62 / $2,815.13
| Professional | | $2,054.63 | $2,262.62 | $2,815.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.20 / $2,460.80 / $2,460.80
| Professional | | $2,011.20 | $2,460.80 | $2,460.80 |