- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.53 / $1,230.53 / $1,230.53
| Facility | | $1,230.53 | $1,230.53 | $1,230.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.82 / $2,079.60 / $3,319.18
| Facility | | $1,520.82 | $2,079.60 | $3,319.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,318.00 / $2,897.64 / $3,782.36
| Facility | | $2,318.00 | $2,897.64 | $3,782.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.70 / $2,060.23 / $2,348.89
| Professional | | $1,551.70 | $2,060.23 | $2,348.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $461.73 / $461.73 / $461.73
| Professional | AS | $461.73 | $461.73 | $461.73 |
- 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 |