- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,467.08 / $2,467.08 / $2,467.08
| Facility | | $2,467.08 | $2,467.08 | $2,467.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,376.36 / $3,956.83 / $6,446.21
| Facility | | $2,376.36 | $3,956.83 | $6,446.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,299.00 / $5,750.84 / $7,486.51
| Facility | | $4,299.00 | $5,750.84 | $7,486.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.89 / $4,094.93 / $4,668.68
| Professional | | $3,060.89 | $4,094.93 | $4,668.68 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $913.43 / $913.43 / $913.43
| Professional | AS | $913.43 | $913.43 | $913.43 |
- 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 |