- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $647.74 / $647.74 / $3,511.00
| Facility | | $647.74 | $647.74 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.25 / $1,094.68 / $1,673.86
| Facility | | $847.25 | $1,094.68 | $1,673.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,596.02 / $3,711.03
| Facility | | $1,089.00 | $1,596.02 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.32 / $1,086.59 / $1,282.16
| Professional | | $790.32 | $1,086.59 | $1,282.16 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $237.94 / $237.94 / $237.94
| Professional | AS | $237.94 | $237.94 | $237.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |