- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,116.99 / $3,116.99 / $3,116.99
| Facility | | $3,116.99 | $3,116.99 | $3,116.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.03 / $4,777.56 / $8,462.46
| Facility | | $3,325.03 | $4,777.56 | $8,462.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,452.71 / $8,386.86 / $10,908.05
| Facility | | $6,452.71 | $8,386.86 | $10,908.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,376.85 / $5,846.91 / $6,811.21
| Professional | | $4,376.85 | $5,846.91 | $6,811.21 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,340.16 / $1,340.16 / $1,340.16
| Professional | AS | $1,340.16 | $1,340.16 | $1,340.16 |
- 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 |