- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.08 / $721.08 / $721.08
| Facility | | $721.08 | $721.08 | $721.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $849.32 / $1,218.63 / $1,916.65
| Facility | | $849.32 | $1,218.63 | $1,916.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.81 / $1,748.26 / $2,247.30
| Facility | | $1,090.81 | $1,748.26 | $2,247.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.52 / $1,234.08 / $1,419.30
| Professional | | $912.52 | $1,234.08 | $1,419.30 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $271.52 / $271.52 / $271.52
| Professional | AS | $271.52 | $271.52 | $271.52 |
- 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 |