- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.83 / $265.83 / $265.83
| Facility | | $265.83 | $265.83 | $265.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $348.30 / $449.27 / $764.47
| Facility | | $348.30 | $449.27 | $764.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.77 / $645.23 / $903.10
| Facility | | $430.77 | $645.23 | $903.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.78 / $499.31 / $569.27
| Professional | | $361.78 | $499.31 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $110.67 / $110.67 / $110.67
| Professional | AS | $110.67 | $110.67 | $110.67 |
- 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 |