- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.22 / $963.22 / $963.22
| Facility | | $963.22 | $963.22 | $963.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.53 / $1,615.72 / $2,671.07
| Facility | | $1,176.53 | $1,615.72 | $2,671.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,502.83 / $2,471.13 / $3,248.42
| Facility | | $1,502.83 | $2,471.13 | $3,248.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.30 / $1,787.60 / $2,081.08
| Professional | | $1,271.30 | $1,787.60 | $2,081.08 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $390.95 / $390.95 / $390.95
| Professional | AS | $390.95 | $390.95 | $390.95 |
- 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 |