- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $856.44 / $856.44 / $856.44
| Facility | | $856.44 | $856.44 | $856.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.58 / $1,389.00 / $2,275.98
| Facility | | $1,007.58 | $1,389.00 | $2,275.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.82 / $2,076.21 / $2,680.09
| Facility | | $1,299.82 | $2,076.21 | $2,680.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.13 / $1,463.84 / $1,691.00
| Professional | | $1,086.13 | $1,463.84 | $1,691.00 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $323.91 / $323.91 / $323.91
| Professional | AS | $323.91 | $323.91 | $323.91 |
- 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 |