- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.23 / $622.34 / $622.34
| Facility | | $408.23 | $622.34 | $622.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $587.11 / $884.14 / $1,433.46
| Facility | | $587.11 | $884.14 | $1,433.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.40 / $1,325.32 / $8,250.46
| Facility | | $934.40 | $1,325.32 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.17 / $804.10 / $1,178.00
| Professional | | $601.17 | $804.10 | $1,178.00 |
- 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 |