- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.73 / $1,978.73 / $1,978.73
| Facility | | $1,978.73 | $1,978.73 | $1,978.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,978.73
| Professional | | $1,902.62 | $1,902.62 | $1,978.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.93 / $1,902.62 / $1,902.62
| Facility | | $1,794.93 | $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
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |