- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,805.68 / $5,805.68 / $5,805.68
| Facility | | $5,805.68 | $5,805.68 | $5,805.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.47 / $1,985.47 / $1,985.47
| Professional | | $1,985.47 | $1,985.47 | $1,985.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.73 / $99.73 / $99.73
| Professional | | $99.73 | $99.73 | $99.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $5,607.06
| Professional | | $1,055.57 | $1,507.95 | $5,607.06 |