- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.38 / $4,338.00 / $6,083.59
| Facility | | $536.38 | $4,338.00 | $6,083.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.91 / $851.35 / $1,384.50
| Facility | | $648.91 | $851.35 | $1,384.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.21 / $1,419.01 / $2,824.47
| Facility | | $989.21 | $1,419.01 | $2,824.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.20 / $907.88 / $1,068.03
| Professional | | $660.20 | $907.88 | $1,068.03 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $197.54 / $197.54 / $197.54
| Professional | AS | $197.54 | $197.54 | $197.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |