- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,885.97 / $1,885.97 / $1,885.97
| Facility | | $1,885.97 | $1,885.97 | $1,885.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,311.54 / $3,187.29 / $5,307.66
| Facility | | $2,311.54 | $3,187.29 | $5,307.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,972.98 / $4,449.35 / $6,420.72
| Facility | | $2,972.98 | $4,449.35 | $6,420.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.36 / $3,558.37 / $4,107.17
| Professional | | $2,558.36 | $3,558.37 | $4,107.17 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $777.66 / $777.66 / $777.66
| Professional | AS | $777.66 | $777.66 | $777.66 |
- 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 |