- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.19 / $3,128.00 / $3,128.00
| Professional | | $2,539.19 | $3,128.00 | $3,128.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.50 / $1,192.50 / $1,192.50
| Facility | | $1,192.50 | $1,192.50 | $1,192.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.50 / $3,128.00 / $3,128.00
| Professional | | $1,192.50 | $3,128.00 | $3,128.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.50 / $1,192.50 / $1,192.50
| Facility | | $1,192.50 | $1,192.50 | $1,192.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.50 / $3,128.00 / $3,128.00
| Professional | | $1,192.50 | $3,128.00 | $3,128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.00 / $3,200.00 / $9,600.00
| Professional | | $3,200.00 | $3,200.00 | $9,600.00 |