- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.66 / $934.66 / $934.66
| Facility | | $934.66 | $934.66 | $934.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.48 / $1,525.72 / $2,501.42
| Facility | | $1,098.48 | $1,525.72 | $2,501.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.28 / $2,268.66 / $2,933.48
| Facility | | $1,425.28 | $2,268.66 | $2,933.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.22 / $1,609.47 / $1,843.02
| Professional | | $1,191.22 | $1,609.47 | $1,843.02 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $354.79 / $354.79 / $354.79
| Professional | AS | $354.79 | $354.79 | $354.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |