- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.58 / $627.52 / $627.52
| Facility | | $421.58 | $627.52 | $627.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.15 / $887.77 / $1,436.17
| Facility | | $602.15 | $887.77 | $1,436.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.77 / $1,342.78 / $3,711.03
| Facility | | $933.77 | $1,342.78 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.49 / $829.97 / $1,193.53
| Professional | | $602.49 | $829.97 | $1,193.53 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $227.52 / $227.52 / $227.52
| Professional | AS | $227.52 | $227.52 | $227.52 |
- 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 |