- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.05 / $525.05 / $4,338.00
| Facility | | $525.05 | $525.05 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.34 / $940.02 / $1,590.56
| Facility | | $568.34 | $940.02 | $1,590.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $856.64 / $1,396.53 / $3,960.15
| Facility | | $856.64 | $1,396.53 | $3,960.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.01 / $963.71 / $1,139.83
| Professional | | $694.01 | $963.71 | $1,139.83 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $214.65 / $214.65 / $214.65
| Professional | AS | $214.65 | $214.65 | $214.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |