- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.46 / $1,175.46 / $1,175.46
| Facility | | $1,175.46 | $1,175.46 | $1,175.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.41 / $1,913.03 / $3,065.92
| Facility | | $1,437.41 | $1,913.03 | $3,065.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.06 / $3,114.47 / $8,250.46
| Facility | | $2,172.06 | $3,114.47 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.63 / $1,983.49 / $2,333.37
| Professional | | $1,447.63 | $1,983.49 | $2,333.37 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $435.74 / $435.74 / $435.74
| Professional | AS | $435.74 | $435.74 | $435.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |