- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,754.40 / $10,000.00
| Facility | | $912.01 | $5,754.40 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,454.71
| Facility | | $1,122.02 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,089.30
| Professional | | $1,949.84 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $1,819.70
| Professional | | $1,047.13 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | AS | $354.81 | $354.81 | $354.81 |
- 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 |