- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.91 / $575.91 / $3,511.00
| Facility | | $575.91 | $575.91 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $753.04 / $968.82 / $1,478.06
| Facility | | $753.04 | $968.82 | $1,478.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.65 / $1,416.12 / $10,733.39
| Facility | | $1,060.65 | $1,416.12 | $10,733.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.08 / $960.95 / $1,137.90
| Professional | | $692.08 | $960.95 | $1,137.90 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $210.40 / $210.40 / $210.40
| Professional | AS | $210.40 | $210.40 | $210.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |