- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.25 / $829.25 / $10,670.40
| Facility | | $829.25 | $829.25 | $10,670.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.98 / $1,290.09 / $2,146.08
| Facility | | $1,004.98 | $1,290.09 | $2,146.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.00 / $2,046.01 / $11,196.08
| Facility | | $1,392.00 | $2,046.01 | $11,196.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.92 / $1,395.70 / $1,647.65
| Professional | | $935.92 | $1,395.70 | $1,647.65 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $305.25 / $305.25 / $305.25
| Professional | AS | $305.25 | $305.25 | $305.25 |
- 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 |