- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $4,365.16
| Facility | | $501.19 | $501.19 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,318.26
| Facility | | $616.60 | $851.14 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,148.15
| Professional | | $1,047.13 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $851.14 / $1,000.00
| Professional | | $575.44 | $851.14 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | AS | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |