- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.32 / $985.32 / $985.32
| Facility | | $985.32 | $985.32 | $985.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.22 / $1,660.17 / $2,591.65
| Facility | | $1,294.22 | $1,660.17 | $2,591.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.30 / $2,248.17 / $3,088.88
| Facility | | $1,490.30 | $2,248.17 | $3,088.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.09 / $1,670.60 / $1,965.28
| Professional | | $1,227.09 | $1,670.60 | $1,965.28 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $368.69 / $368.69 / $368.69
| Professional | AS | $368.69 | $368.69 | $368.69 |
- 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 |