- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $786.35 / $786.35 / $786.35
| Facility | | $786.35 | $786.35 | $786.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $962.65 / $1,328.93 / $2,091.96
| Facility | | $962.65 | $1,328.93 | $2,091.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,390.00 / $1,781.21 / $2,358.88
| Facility | | $1,390.00 | $1,781.21 | $2,358.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.41 / $1,301.05 / $1,483.34
| Professional | | $995.41 | $1,301.05 | $1,483.34 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $296.24 / $296.24 / $296.24
| Professional | AS | $296.24 | $296.24 | $296.24 |
- 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 |