- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $873.67 / $873.67 / $873.67
| Facility | | $873.67 | $873.67 | $873.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.33 / $1,476.50 / $2,339.61
| Facility | | $1,027.33 | $1,476.50 | $2,339.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.39 / $2,120.65 / $2,740.57
| Facility | | $1,330.39 | $2,120.65 | $2,740.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.60 / $1,506.78 / $1,723.99
| Professional | | $1,113.60 | $1,506.78 | $1,723.99 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $331.37 / $331.37 / $331.37
| Professional | AS | $331.37 | $331.37 | $331.37 |
- 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 |