- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,009.59 / $4,009.59 / $4,009.59
| Facility | | $4,009.59 | $4,009.59 | $4,009.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,188.57 / $4,009.59 / $4,009.59
| Professional | | $2,188.57 | $4,009.59 | $4,009.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.20 / $3,441.20 / $3,441.20
| Professional | | $3,441.20 | $3,441.20 | $3,441.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $6,067.50
| Professional | | $248.35 | $248.35 | $6,067.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $253.82 / $2,157.78
| Professional | | $151.16 | $253.82 | $2,157.78 |