- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $4,365.16
| Facility | | $257.04 | $257.04 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $436.52 / $676.08
| Facility | | $346.74 | $436.52 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $588.84
| Professional | | $549.54 | $549.54 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $426.58 / $489.78
| Professional | | $346.74 | $426.58 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | AS | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |