- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.08 / $782.08 / $782.08
| Facility | | $782.08 | $782.08 | $782.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.40 / $1,086.57 / $2,108.11
| Facility | | $919.40 | $1,086.57 | $2,108.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,199.33 / $1,900.72 / $2,457.96
| Facility | | $1,199.33 | $1,900.72 | $2,457.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.90 / $1,355.93 / $1,548.68
| Professional | | $1,002.90 | $1,355.93 | $1,548.68 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $298.43 / $298.43 / $298.43
| Professional | AS | $298.43 | $298.43 | $298.43 |
- 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 |