- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.88 / $733.88 / $733.88
| Facility | | $733.88 | $733.88 | $733.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.55 / $1,240.26 / $1,908.30
| Facility | | $961.55 | $1,240.26 | $1,908.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $1,806.01 / $11,275.82
| Facility | | $1,285.00 | $1,806.01 | $11,275.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.16 / $1,235.63 / $1,453.58
| Professional | | $900.16 | $1,235.63 | $1,453.58 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $270.50 / $270.50 / $270.50
| Professional | AS | $270.50 | $270.50 | $270.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $14,287.46
| Facility | | $5,357.00 | $5,357.00 | $14,287.46 |