- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.13 / $2,773.13 / $2,773.13
| Facility | | $2,773.13 | $2,773.13 | $2,773.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.25 / $4,337.10 / $7,245.43
| Facility | | $2,671.25 | $4,337.10 | $7,245.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.77 / $6,167.21 / $8,417.75
| Facility | | $4,265.77 | $6,167.21 | $8,417.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.89 / $4,602.75 / $5,247.65
| Professional | | $3,441.89 | $4,602.75 | $5,247.65 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,028.34 / $1,028.34 / $1,028.34
| Professional | AS | $1,028.34 | $1,028.34 | $1,028.34 |
- 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 |