- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $902.16 / $17,100.00 / $21,700.37
| Facility | | $902.16 | $17,100.00 | $21,700.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,110.86 / $1,474.04 / $2,345.36
| Facility | | $1,110.86 | $1,474.04 | $2,345.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,353.02 / $2,226.81 / $11,059.41
| Facility | | $1,353.02 | $2,226.81 | $11,059.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.40 / $1,525.42 / $1,794.50
| Professional | | $1,110.40 | $1,525.42 | $1,794.50 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $334.07 / $334.07 / $334.07
| Professional | AS | $334.07 | $334.07 | $334.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |