- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,315.48 / $1,315.48 / $4,338.00
| Facility | | $1,315.48 | $1,315.48 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,728.51 / $2,223.16 / $3,515.96
| Facility | | $1,728.51 | $2,223.16 | $3,515.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.78 / $3,031.78 / $4,201.56
| Facility | | $2,008.78 | $3,031.78 | $4,201.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.12 / $2,295.28 / $2,700.16
| Professional | | $1,676.12 | $2,295.28 | $2,700.16 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $506.26 / $506.26 / $506.26
| Professional | AS | $506.26 | $506.26 | $506.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |