- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,874.14 / $1,874.14 / $1,874.14
| Facility | | $1,874.14 | $1,874.14 | $1,874.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,092.53 / $3,167.30 / $5,292.19
| Facility | | $2,092.53 | $3,167.30 | $5,292.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,974.50 / $4,845.97 / $6,395.70
| Facility | | $2,974.50 | $4,845.97 | $6,395.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,613.41 / $3,551.98 / $4,088.41
| Professional | | $2,613.41 | $3,551.98 | $4,088.41 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $777.66 / $777.66 / $777.66
| Professional | AS | $777.66 | $777.66 | $777.66 |
- 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 |