- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,115.73 / $2,115.73 / $2,115.73
| Facility | | $2,115.73 | $2,115.73 | $2,115.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,590.12 / $3,462.07 / $5,894.20
| Facility | | $2,590.12 | $3,462.07 | $5,894.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,345.22 / $5,006.58 / $7,009.93
| Facility | | $3,345.22 | $5,006.58 | $7,009.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.17 / $3,865.29 / $4,520.54
| Professional | | $2,577.17 | $3,865.29 | $4,520.54 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $850.24 / $850.24 / $850.24
| Professional | AS | $850.24 | $850.24 | $850.24 |
- 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 |