- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.84 / $1,054.84 / $1,054.84
| Facility | | $1,054.84 | $1,054.84 | $1,054.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,289.39 / $1,782.70 / $2,936.40
| Facility | | $1,289.39 | $1,782.70 | $2,936.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,656.06 / $2,710.95 / $3,539.36
| Facility | | $1,656.06 | $2,710.95 | $3,539.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.37 / $1,955.27 / $2,271.27
| Professional | | $1,435.37 | $1,955.27 | $2,271.27 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $427.12 / $427.12 / $427.12
| Professional | AS | $427.12 | $427.12 | $427.12 |
- 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 |