- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $3,090.30 / $4,365.16
| Facility | | $371.54 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $645.65 / $1,071.52
| Facility | | $489.78 | $645.65 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $870.96 / $870.96
| Professional | | $794.33 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $758.58
| Professional | | $478.63 | $660.69 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | AS | $144.54 | $144.54 | $144.54 |
- 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 |