- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.98 / $832.98 / $3,511.00
| Facility | | $832.98 | $832.98 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.34 / $1,407.13 / $2,178.61
| Facility | | $1,091.34 | $1,407.13 | $2,178.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.47 / $2,056.58 / $19,943.06
| Facility | | $1,255.47 | $2,056.58 | $19,943.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.46 / $1,409.39 / $1,658.00
| Professional | | $1,030.46 | $1,409.39 | $1,658.00 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $309.62 / $309.62 / $309.62
| Professional | AS | $309.62 | $309.62 | $309.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $25,733.64
| Facility | | $5,357.00 | $5,357.00 | $25,733.64 |