- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,681.37 / $2,681.37 / $2,681.37
| Facility | | $2,681.37 | $2,681.37 | $2,681.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.15 / $2,681.37 / $2,681.37
| Professional | | $1,316.15 | $2,681.37 | $2,681.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,301.50 / $4,301.50 / $4,301.50
| Professional | | $4,301.50 | $4,301.50 | $4,301.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $226.80 / $2,475.60
| Professional | | $95.50 | $226.80 | $2,475.60 |