- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,607.60 / $3,607.60 / $3,607.60
| Facility | | $3,607.60 | $3,607.60 | $3,607.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $3,574.00 / $3,607.60
| Professional | | $2,859.20 | $3,574.00 | $3,607.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,607.60 / $3,607.60 / $3,607.60
| Facility | | $3,607.60 | $3,607.60 | $3,607.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.19 / $2,239.19 / $3,607.60
| Professional | | $2,239.19 | $2,239.19 | $3,607.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,044.96 / $2,488.00
| Professional | | $1,044.96 | $1,044.96 | $2,488.00 |