- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $864.36 / $864.36 / $864.36
| Facility | | $864.36 | $864.36 | $864.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,025.00 / $1,443.61 / $2,292.13
| Facility | | $1,025.00 | $1,443.61 | $2,292.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.00 / $2,333.60 / $5,090.60
| Facility | | $1,375.00 | $2,333.60 | $5,090.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.77 / $1,473.18 / $1,733.05
| Professional | | $991.77 | $1,473.18 | $1,733.05 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $327.38 / $327.38 / $327.38
| Professional | AS | $327.38 | $327.38 | $327.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |