- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.94 / $1,178.94 / $1,178.94
| Facility | | $1,178.94 | $1,178.94 | $1,178.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.71 / $1,638.84 / $3,193.54
| Facility | | $1,386.71 | $1,638.84 | $3,193.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.36 / $2,871.46 / $3,722.91
| Facility | | $1,812.36 | $2,871.46 | $3,722.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.80 / $2,046.04 / $2,332.71
| Professional | | $1,516.80 | $2,046.04 | $2,332.71 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $450.67 / $450.67 / $450.67
| Professional | AS | $450.67 | $450.67 | $450.67 |
- 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 |