- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $767.61 / $767.61 / $2,290.00
| Facility | | $767.61 | $767.61 | $2,290.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $990.26 / $1,274.30 / $1,786.54
| Facility | | $990.26 | $1,274.30 | $1,786.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.14 / $1,836.27 / $3,711.03
| Facility | | $1,041.14 | $1,836.27 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.87 / $1,159.74 / $1,460.70
| Professional | | $766.87 | $1,159.74 | $1,460.70 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $254.16 / $254.16 / $254.16
| Professional | AS | $254.16 | $254.16 | $254.16 |
- 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 |