- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.21 / $188.21 / $188.21
| Facility | | $188.21 | $188.21 | $188.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.47 / $295.31 / $561.72
| Facility | | $181.47 | $295.31 | $561.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $399.16 / $441.23 / $577.74
| Facility | | $399.16 | $441.23 | $577.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.84 / $313.55 / $361.46
| Professional | | $250.84 | $313.55 | $361.46 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $74.64 / $74.64 / $74.64
| Professional | AS | $74.64 | $74.64 | $74.64 |
- 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 |