- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.12 / $536.73 / $3,634.42
| Facility | | $357.12 | $536.73 | $3,634.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $513.22 / $762.22 / $1,235.79
| Facility | | $513.22 | $762.22 | $1,235.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.58 / $1,152.83 / $3,711.03
| Facility | | $814.58 | $1,152.83 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.71 / $705.12 / $1,024.69
| Professional | | $525.71 | $705.12 | $1,024.69 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $198.31 / $198.31 / $198.31
| Professional | AS | $198.31 | $198.31 | $198.31 |
- 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 |