- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $1,908.26
| Facility | | $1,908.26 | $1,908.26 | $1,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $2,501.75
| Professional | | $1,908.26 | $1,908.26 | $2,501.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,908.50 / $5,908.50 / $5,908.50
| Professional | | $5,908.50 | $5,908.50 | $5,908.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $2,501.75
| Facility | | $1,908.26 | $1,908.26 | $2,501.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.75 / $2,501.75 / $2,501.75
| Professional | | $2,501.75 | $2,501.75 | $2,501.75 |