- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.25 / $920.25 / $920.25
| Facility | | $920.25 | $920.25 | $920.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.20 / $1,428.12 / $2,426.71
| Facility | | $1,115.20 | $1,428.12 | $2,426.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.01 / $2,279.34 / $21,075.51
| Facility | | $1,397.01 | $2,279.34 | $21,075.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.28 / $1,561.72 / $1,837.20
| Professional | | $1,147.28 | $1,561.72 | $1,837.20 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $344.63 / $344.63 / $344.63
| Professional | AS | $344.63 | $344.63 | $344.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |