- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Facility | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $2,092.88
| Professional | | $1,902.62 | $1,902.62 | $2,092.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Facility | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.28 / $1,902.62 / $1,902.62
| Professional | | $1,655.28 | $1,902.62 | $1,902.62 |