- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $8,500.00
| Facility | | $1,987.50 | $1,987.50 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $1,987.50
| Professional | | $1,987.50 | $1,987.50 | $1,987.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.38 / $4,491.24 / $5,888.13
| Professional | | $3,014.38 | $4,491.24 | $5,888.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.50 / $1,987.50 / $3,676.88
| Facility | | $1,987.50 | $1,987.50 | $3,676.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |