- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,548.13 / $4,365.16
| Facility | | $776.25 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,089.30
| Facility | | $1,000.00 | $1,288.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $1,819.70
| Professional | | $1,698.24 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $1,513.56
| Professional | | $954.99 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | AS | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |