- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,223.21 / $3,223.21 / $3,223.21
| Facility | | $3,223.21 | $3,223.21 | $3,223.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,114.64 / $5,032.14 / $8,483.92
| Facility | | $3,114.64 | $5,032.14 | $8,483.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,547.00 / $7,217.96 / $9,839.15
| Facility | | $5,547.00 | $7,217.96 | $9,839.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,033.56 / $5,363.06 / $6,114.50
| Professional | | $4,033.56 | $5,363.06 | $6,114.50 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,204.65 / $1,204.65 / $1,204.65
| Professional | AS | $1,204.65 | $1,204.65 | $1,204.65 |
- 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 |