- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $4,365.16
| Facility | | $537.03 | $537.03 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,380.38
| Facility | | $645.65 | $870.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,202.26
| Professional | | $1,096.48 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $1,047.13
| Professional | | $588.84 | $891.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Professional | AS | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |