- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $754.41 / $754.41 / $754.41
| Facility | | $754.41 | $754.41 | $754.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $943.04 / $1,274.95 / $2,011.30
| Facility | | $943.04 | $1,274.95 | $2,011.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,295.00 / $2,086.77 / $4,968.71
| Facility | | $1,295.00 | $2,086.77 | $4,968.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.35 / $1,323.06 / $1,556.44
| Professional | | $954.35 | $1,323.06 | $1,556.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $285.30 / $285.30 / $285.30
| Professional | AS | $285.30 | $285.30 | $285.30 |
- 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 |