- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,253.50 / $4,253.50 / $4,253.50
| Facility | | $4,253.50 | $4,253.50 | $4,253.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.62 / $1,112.45 / $1,112.45
| Professional | | $741.62 | $1,112.45 | $1,112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,348.96 / $2,348.96 / $2,609.96
| Facility | | $2,348.96 | $2,348.96 | $2,609.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.03 / $1,271.59 / $2,050.60
| Professional | | $0.03 | $1,271.59 | $2,050.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,308.77
| Professional | | $1,308.77 | $1,308.77 | $1,308.77 |