- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.05 / $505.05 / $3,511.00
| Facility | | $505.05 | $505.05 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $627.82 / $853.92 / $1,401.38
| Facility | | $627.82 | $853.92 | $1,401.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.47 / $1,264.06 / $2,173.59
| Facility | | $948.47 | $1,264.06 | $2,173.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.44 / $881.17 / $1,004.64
| Professional | | $630.44 | $881.17 | $1,004.64 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $193.03 / $193.03 / $193.03
| Professional | AS | $193.03 | $193.03 | $193.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |