- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,443.58 / $2,443.58 / $2,443.58
| Facility | | $2,443.58 | $2,443.58 | $2,443.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,349.42 / $3,816.88 / $6,341.09
| Facility | | $2,349.42 | $3,816.88 | $6,341.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,195.00 / $5,527.15 / $7,411.42
| Facility | | $4,195.00 | $5,527.15 | $7,411.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.41 / $4,048.40 / $4,615.63
| Professional | | $3,012.41 | $4,048.40 | $4,615.63 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $900.43 / $900.43 / $900.43
| Professional | AS | $900.43 | $900.43 | $900.43 |
- 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 |