- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $778.62 / $778.62 / $4,338.00
| Facility | | $778.62 | $778.62 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.00 / $1,233.70 / $1,812.20
| Facility | | $927.00 | $1,233.70 | $1,812.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.00 / $1,851.51 / $10,853.69
| Facility | | $1,392.00 | $1,851.51 | $10,853.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.32 / $1,179.21 / $1,468.46
| Professional | | $797.32 | $1,179.21 | $1,468.46 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $258.52 / $258.52 / $258.52
| Professional | AS | $258.52 | $258.52 | $258.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |