- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $2,500.00
| Facility | | $1,748.25 | $1,748.25 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.54 / $1,748.25 / $1,748.25
| Professional | | $1,686.54 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.41 / $1,713.97 / $2,056.76
| Professional | | $1,633.41 | $1,713.97 | $2,056.76 |