- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.65 / $1,567.65 / $1,567.65
| Facility | | $1,567.65 | $1,567.65 | $1,567.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.83 / $2,176.69 / $4,184.39
| Facility | | $1,841.83 | $2,176.69 | $4,184.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,380.09 / $3,804.81 / $4,924.26
| Facility | | $2,380.09 | $3,804.81 | $4,924.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.82 / $2,692.13 / $3,088.95
| Professional | | $1,990.82 | $2,692.13 | $3,088.95 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $593.64 / $593.64 / $593.64
| Professional | AS | $593.64 | $593.64 | $593.64 |
- 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 |