- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.58 / $827.58 / $827.58
| Facility | | $827.58 | $827.58 | $827.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.91 / $1,357.00 / $2,269.61
| Facility | | $1,012.91 | $1,357.00 | $2,269.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.50 / $2,122.23 / $2,773.96
| Facility | | $1,284.50 | $2,122.23 | $2,773.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.77 / $1,514.97 / $1,782.21
| Professional | | $1,115.77 | $1,514.97 | $1,782.21 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $332.01 / $332.01 / $332.01
| Professional | AS | $332.01 | $332.01 | $332.01 |
- 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 |