- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.69 / $824.69 / $824.69
| Facility | | $824.69 | $824.69 | $824.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.50 / $1,363.42 / $2,543.73
| Facility | | $898.50 | $1,363.42 | $2,543.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,399.94 / $2,091.46 / $2,863.63
| Facility | | $1,399.94 | $2,091.46 | $2,863.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.74 / $1,564.22 / $1,802.26
| Professional | | $1,082.74 | $1,564.22 | $1,802.26 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $346.17 / $346.17 / $346.17
| Professional | AS | $346.17 | $346.17 | $346.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |