- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.81 / $680.81 / $3,511.00
| Facility | | $680.81 | $680.81 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.58 / $1,094.83 / $1,808.64
| Facility | | $824.58 | $1,094.83 | $1,808.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.79 / $1,802.85 / $2,824.47
| Facility | | $1,261.79 | $1,802.85 | $2,824.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.69 / $1,164.69 / $1,370.13
| Professional | | $857.69 | $1,164.69 | $1,370.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $257.25 / $257.25 / $257.25
| Professional | AS | $257.25 | $257.25 | $257.25 |
- 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 |