- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $724.44 / $4,365.16
| Facility | | $537.03 | $724.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,584.89
| Facility | | $776.25 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,202.26 / $1,584.89
| Professional | | $1,174.90 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,412.54
| Professional | | $794.33 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Professional | AS | $263.03 | $263.03 | $263.03 |
- 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 |