- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.39 / $910.39 / $910.39
| Facility | | $910.39 | $910.39 | $910.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.43 / $1,263.86 / $2,440.32
| Facility | | $1,069.43 | $1,263.86 | $2,440.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.18 / $2,208.56 / $2,858.43
| Facility | | $1,388.18 | $2,208.56 | $2,858.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.48 / $1,570.60 / $1,795.15
| Professional | | $1,162.48 | $1,570.60 | $1,795.15 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $345.91 / $345.91 / $345.91
| Professional | AS | $345.91 | $345.91 | $345.91 |
- 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 |