- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.27 / $2,561.27 / $2,561.27
| Facility | | $2,561.27 | $2,561.27 | $2,561.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,473.56 / $4,001.31 / $6,672.71
| Facility | | $2,473.56 | $4,001.31 | $6,672.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.00 / $5,690.74 / $7,770.16
| Facility | | $4,303.00 | $5,690.74 | $7,770.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,786.99 / $4,261.17 / $4,858.22
| Professional | | $2,786.99 | $4,261.17 | $4,858.22 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $947.79 / $947.79 / $947.79
| Professional | AS | $947.79 | $947.79 | $947.79 |
- 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 |