- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $4,365.16
| Facility | | $436.52 | $436.52 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,122.02
| Facility | | $575.44 | $741.31 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $977.24
| Professional | | $891.25 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $724.44 / $870.96
| Professional | | $478.63 | $724.44 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | AS | $162.18 | $162.18 | $162.18 |
- 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 |