- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,112.73 / $3,112.73 / $3,112.73
| Facility | | $3,112.73 | $3,112.73 | $3,112.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,905.46 / $4,853.27 / $8,130.66
| Facility | | $2,905.46 | $4,853.27 | $8,130.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,762.00 / $6,917.78 / $9,389.67
| Facility | | $4,762.00 | $6,917.78 | $9,389.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,439.66 / $5,137.24 / $5,857.03
| Professional | | $3,439.66 | $5,137.24 | $5,857.03 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,151.89 / $1,151.89 / $1,151.89
| Professional | AS | $1,151.89 | $1,151.89 | $1,151.89 |
- 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 |