- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.11 / $724.11 / $724.11
| Facility | | $724.11 | $724.11 | $724.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $990.83 / $1,209.77 / $2,064.15
| Facility | | $990.83 | $1,209.77 | $2,064.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.16 / $1,878.94 / $2,422.50
| Facility | | $1,175.16 | $1,878.94 | $2,422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.12 / $1,328.08 / $1,526.68
| Professional | | $982.12 | $1,328.08 | $1,526.68 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $292.51 / $292.51 / $292.51
| Professional | AS | $292.51 | $292.51 | $292.51 |
- 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 |