- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.75 / $2,004.75 / $2,004.75
| Professional | | $2,004.75 | $2,004.75 | $2,004.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Facility | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.73 / $1,171.73 / $1,673.90
| Professional | | $1,171.73 | $1,171.73 | $1,673.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $2,866.79
| Facility | | $1,262.25 | $1,262.25 | $2,866.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.73 / $1,262.25 / $1,782.00
| Professional | | $1,171.73 | $1,262.25 | $1,782.00 |