- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,052.60 / $2,326.28 / $2,985.60
| Facility | | $2,052.60 | $2,326.28 | $2,985.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,985.60 / $2,985.60 / $2,985.60
| Professional | | $2,985.60 | $2,985.60 | $2,985.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.16 / $587.16 / $587.16
| Professional | | $587.16 | $587.16 | $587.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.00 / $2,985.60 / $3,732.00
| Professional | | $2,488.00 | $2,985.60 | $3,732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $2,985.60 / $3,732.00
| Professional | | $1,044.96 | $2,985.60 | $3,732.00 |