- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.31 / $1,477.31 / $1,477.31
| Facility | | $1,477.31 | $1,477.31 | $1,477.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,730.21 / $2,366.28 / $4,125.99
| Facility | | $1,730.21 | $2,366.28 | $4,125.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,391.41 / $3,794.52 / $4,803.29
| Facility | | $2,391.41 | $3,794.52 | $4,803.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.63 / $2,620.17 / $3,047.55
| Professional | | $1,955.63 | $2,620.17 | $3,047.55 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $581.92 / $581.92 / $581.92
| Professional | AS | $581.92 | $581.92 | $581.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |