- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.41 / $1,811.41 / $1,811.41
| Professional | | $1,811.41 | $1,811.41 | $1,811.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.00 / $2,141.00 / $2,141.00
| Professional | | $2,141.00 | $2,141.00 | $2,141.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,122.26 / $4,122.26 / $4,122.26
| Facility | | $4,122.26 | $4,122.26 | $4,122.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,628.00 / $1,628.00 / $1,628.00
| Facility | | $1,628.00 | $1,628.00 | $1,628.00 |