- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $4,365.16
| Facility | | $758.58 | $758.58 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $1,949.84
| Facility | | $977.24 | $1,258.93 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $1,698.24
| Professional | | $1,548.82 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $1,479.11
| Professional | | $851.14 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | AS | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |