- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,677.92 / $1,677.92 / $1,677.92
| Facility | | $1,677.92 | $1,677.92 | $1,677.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.92 / $2,039.02 / $3,107.21
| Professional | | $1,677.92 | $2,039.02 | $3,107.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,669.57 / $2,853.06 / $4,565.92
| Facility | | $2,669.57 | $2,853.06 | $4,565.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,082.73 / $3,998.08
| Professional | | $2,082.73 | $2,082.73 | $3,998.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,171.31 / $4,200.64 / $5,981.36
| Professional | | $4,171.31 | $4,200.64 | $5,981.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,345.92 / $4,565.92 / $4,565.92
| Professional | | $4,345.92 | $4,565.92 | $4,565.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.79 / $2,607.55 / $4,191.75
| Professional | | $2,058.79 | $2,607.55 | $4,191.75 |