- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,801.89
| Facility | | $3,162.28 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $3,162.28
| Professional | | $1,737.80 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $3.98 / $3.98
| Professional | | $3.98 | $3.98 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $3,467.37
| Professional | | $1,949.84 | $2,818.38 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,467.37
| Professional | | $2,041.74 | $2,398.83 | $3,467.37 |