- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $4,365.16
| Facility | | $407.38 | $616.60 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $1,412.54
| Facility | | $575.44 | $891.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $933.25 / $1,412.54
| Professional | | $912.01 | $933.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $891.25 / $1,174.90
| Professional | | $616.60 | $891.25 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Professional | AS | $234.42 | $234.42 | $234.42 |
- 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 |