- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $4,365.16
| Facility | | $794.33 | $794.33 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $1,862.09
| Facility | | $1,000.00 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $1,659.59
| Professional | | $1,479.11 | $1,621.81 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,513.56
| Professional | | $794.33 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Professional | AS | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |