- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,898.75 / $1,898.75 / $3,325.14
| Facility | | $1,898.75 | $1,898.75 | $3,325.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.75 / $1,898.75 / $1,898.75
| Professional | | $1,898.75 | $1,898.75 | $1,898.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $3.00 / $3,304.00
| Professional | | $3.00 | $3.00 | $3,304.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $3,495.28 / $5,263.23
| Facility | | $55.00 | $3,495.28 | $5,263.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,229.42 / $8,229.42 / $8,229.42
| Professional | | $8,229.42 | $8,229.42 | $8,229.42 |