- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,291.67 / $1,291.67 / $1,291.67
| Facility | | $1,291.67 | $1,291.67 | $1,291.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.01 / $2,182.92 / $3,620.20
| Facility | | $1,584.01 | $2,182.92 | $3,620.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.90 / $3,341.04 / $4,354.89
| Facility | | $2,039.90 | $3,341.04 | $4,354.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.42 / $2,420.01 / $2,777.14
| Professional | | $1,774.42 | $2,420.01 | $2,777.14 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $528.01 / $528.01 / $528.01
| Professional | AS | $528.01 | $528.01 | $528.01 |
- 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 |