- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $4,365.16
| Facility | | $724.44 | $724.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $1,995.26
| Facility | | $933.25 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $1,621.81
| Professional | | $1,479.11 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $1,412.54
| Professional | | $812.83 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Professional | AS | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |