- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $905.13 / $905.13 / $905.13
| Facility | | $905.13 | $905.13 | $905.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,065.33 / $1,494.93 / $2,426.67
| Facility | | $1,065.33 | $1,494.93 | $2,426.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.05 / $2,196.48 / $2,842.78
| Facility | | $1,381.05 | $2,196.48 | $2,842.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.11 / $1,562.48 / $1,783.50
| Professional | | $1,155.11 | $1,562.48 | $1,783.50 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $343.73 / $343.73 / $343.73
| Professional | AS | $343.73 | $343.73 | $343.73 |
- 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 |