- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,907.06 / $1,907.06 / $1,907.06
| Facility | | $1,907.06 | $1,907.06 | $1,907.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,346.38 / $3,222.93 / $5,356.64
| Facility | | $2,346.38 | $3,222.93 | $5,356.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,012.05 / $4,504.35 / $6,502.08
| Facility | | $3,012.05 | $4,504.35 | $6,502.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.86 / $3,589.12 / $4,153.10
| Professional | | $2,591.86 | $3,589.12 | $4,153.10 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $787.96 / $787.96 / $787.96
| Professional | AS | $787.96 | $787.96 | $787.96 |
- 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 |