- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.71 / $1,001.71 / $1,001.71
| Facility | | $1,001.71 | $1,001.71 | $1,001.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.71 / $1,066.71 / $1,662.14
| Professional | | $1,001.71 | $1,066.71 | $1,662.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.80 / $1,823.10 / $2,725.82
| Facility | | $1,556.80 | $1,823.10 | $2,725.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,330.86 / $2,386.82
| Professional | | $1,330.86 | $1,330.86 | $2,386.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.23 / $2,507.75 / $3,570.82
| Professional | | $2,490.23 | $2,507.75 | $3,570.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,661.93 / $2,725.82 / $2,725.82
| Professional | | $2,661.93 | $2,725.82 | $2,725.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.79 / $1,537.88 / $2,725.82
| Professional | | $1,163.79 | $1,537.88 | $2,725.82 |