- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.08 / $1,276.08 / $1,276.08
| Facility | | $1,276.08 | $1,276.08 | $1,276.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.22 / $2,156.58 / $3,418.34
| Facility | | $1,577.22 | $2,156.58 | $3,418.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,364.00 / $2,998.71 / $3,937.74
| Facility | | $2,364.00 | $2,998.71 | $3,937.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.03 / $2,141.94 / $2,442.05
| Professional | | $1,604.03 | $2,141.94 | $2,442.05 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $477.30 / $477.30 / $477.30
| Professional | AS | $477.30 | $477.30 | $477.30 |
- 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 |