- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $4,365.16
| Facility | | $851.14 | $851.14 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,238.72
| Facility | | $1,122.02 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $1,949.84
| Professional | | $1,778.28 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $1,698.24
| Professional | | $1,000.00 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Professional | AS | $331.13 | $331.13 | $331.13 |
- 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 |