- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.13 / $1,044.13 / $1,044.13
| Facility | | $1,044.13 | $1,044.13 | $1,044.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.50 / $1,740.99 / $2,990.19
| Facility | | $1,431.50 | $1,740.99 | $2,990.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.14 / $2,707.36 / $3,479.94
| Facility | | $1,697.14 | $2,707.36 | $3,479.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.63 / $1,921.04 / $2,196.23
| Professional | | $1,417.63 | $1,921.04 | $2,196.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $421.84 / $421.84 / $421.84
| Professional | AS | $421.84 | $421.84 | $421.84 |
- 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 |