- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.46 / $161.46 / $161.46
| Facility | | $161.46 | $161.46 | $161.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.20 / $285.83 / $466.91
| Facility | | $219.20 | $285.83 | $466.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.30 / $397.93 / $545.40
| Facility | | $266.30 | $397.93 | $545.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.57 / $297.32 / $344.47
| Professional | | $218.57 | $297.32 | $344.47 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $66.66 / $66.66 / $66.66
| Professional | AS | $66.66 | $66.66 | $66.66 |
- 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 |