- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.53 / $730.86 / $730.86
| Facility | | $534.53 | $730.86 | $730.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.61 / $1,050.83 / $1,703.73
| Facility | | $774.61 | $1,050.83 | $1,703.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,579.32 / $3,711.03
| Facility | | $1,089.00 | $1,579.32 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.56 / $1,058.98 / $1,403.77
| Professional | | $727.56 | $1,058.98 | $1,403.77 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $255.32 / $255.32 / $255.32
| Professional | AS | $255.32 | $255.32 | $255.32 |
- 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 |