- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,133.64 / $2,133.64 / $2,133.64
| Facility | | $2,133.64 | $2,133.64 | $2,133.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,619.64 / $3,510.86 / $5,976.84
| Facility | | $2,619.64 | $3,510.86 | $5,976.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,375.55 / $5,067.24 / $7,194.50
| Facility | | $3,375.55 | $5,067.24 | $7,194.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.72 / $3,956.96 / $4,569.05
| Professional | | $2,870.72 | $3,956.96 | $4,569.05 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $872.76 / $872.76 / $872.76
| Professional | AS | $872.76 | $872.76 | $872.76 |
- 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 |