- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.45 / $418.45 / $3,511.00
| Facility | | $418.45 | $418.45 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.53 / $661.45 / $1,087.49
| Facility | | $507.53 | $661.45 | $1,087.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.10 / $1,062.42 / $1,664.46
| Facility | | $773.10 | $1,062.42 | $1,664.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.01 / $706.62 / $831.27
| Professional | | $514.01 | $706.62 | $831.27 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $154.16 / $154.16 / $154.16
| Professional | AS | $154.16 | $154.16 | $154.16 |
- 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 |