- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.57 / $2,155.57 / $2,155.57
| Facility | | $2,155.57 | $2,155.57 | $2,155.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,408.46 / $3,119.71 / $6,079.64
| Facility | | $2,408.46 | $3,119.71 | $6,079.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,416.56 / $5,578.06 / $7,376.99
| Facility | | $3,416.56 | $5,578.06 | $7,376.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.24 / $4,082.29 / $4,705.55
| Professional | | $2,705.24 | $4,082.29 | $4,705.55 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $897.60 / $897.60 / $897.60
| Professional | AS | $897.60 | $897.60 | $897.60 |
- 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 |