- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,242.50 / $2,242.50 / $2,242.50
| Professional | | $2,242.50 | $2,242.50 | $2,242.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.00 / $2,613.00 / $2,613.00
| Professional | | $2,613.00 | $2,613.00 | $2,613.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,827.50 / $2,827.50 / $2,827.50
| Facility | | $2,827.50 | $2,827.50 | $2,827.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,827.50 / $2,827.50 / $2,827.50
| Professional | | $2,827.50 | $2,827.50 | $2,827.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,827.50 / $2,827.50 / $2,827.50
| Facility | | $2,827.50 | $2,827.50 | $2,827.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $1,755.00 / $2,827.50
| Professional | | $1,755.00 | $1,755.00 | $2,827.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $1,755.00
| Professional | | $737.10 | $737.10 | $1,755.00 |