- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.05 / $363.05 / $363.05
| Facility | | $363.05 | $363.05 | $363.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.69 / $566.96 / $1,154.52
| Facility | | $347.69 | $566.96 | $1,154.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $768.56 / $846.47 / $1,105.42
| Facility | | $768.56 | $846.47 | $1,105.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.47 / $649.02 / $746.21
| Professional | | $496.47 | $649.02 | $746.21 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $159.57 / $159.57 / $159.57
| Professional | AS | $159.57 | $159.57 | $159.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |