- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,732.50 / $1,732.50 / $1,732.50
| Facility | | $1,732.50 | $1,732.50 | $1,732.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.50 / $2,105.36 / $3,065.21
| Professional | | $1,732.50 | $2,105.36 | $3,065.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $4,714.47
| Facility | | $2,886.72 | $2,886.72 | $4,714.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,107.31 / $4,128.16
| Professional | | $2,107.31 | $2,107.31 | $4,128.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,307.01 / $4,337.32 / $6,175.97
| Professional | | $4,307.01 | $4,337.32 | $6,175.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,128.16 / $4,714.47 / $4,714.47
| Professional | | $4,128.16 | $4,714.47 | $4,714.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,890.35 / $5,753.36 / $6,904.03
| Facility | | $4,890.35 | $5,753.36 | $6,904.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.77 / $2,479.86 / $4,714.47
| Professional | | $2,125.77 | $2,479.86 | $4,714.47 |