- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.73 / $510.73 / $510.73
| Facility | | $510.73 | $510.73 | $510.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $665.71 / $858.86 / $1,300.29
| Facility | | $665.71 | $858.86 | $1,300.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $938.21 / $1,285.00 / $3,711.03
| Facility | | $938.21 | $1,285.00 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.55 / $846.51 / $1,007.87
| Professional | | $614.55 | $846.51 | $1,007.87 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $185.05 / $185.05 / $185.05
| Professional | AS | $185.05 | $185.05 | $185.05 |
- 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 |