- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $881.93 / $881.93 / $881.93
| Facility | | $881.93 | $881.93 | $881.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.45 / $1,433.96 / $2,370.84
| Facility | | $1,108.45 | $1,433.96 | $2,370.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.36 / $2,064.71 / $2,908.47
| Facility | | $1,351.36 | $2,064.71 | $2,908.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.73 / $1,582.11 / $1,877.30
| Professional | | $1,150.73 | $1,582.11 | $1,877.30 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $347.20 / $347.20 / $347.20
| Professional | AS | $347.20 | $347.20 | $347.20 |
- 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 |