- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.56 / $790.56 / $790.56
| Facility | | $790.56 | $790.56 | $790.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,315.04 / $1,852.23
| Facility | | $1,000.00 | $1,315.04 | $1,852.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $1,894.99 / $3,711.03
| Facility | | $1,285.00 | $1,894.99 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.57 / $1,204.58 / $1,504.69
| Professional | | $789.57 | $1,204.58 | $1,504.69 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $263.42 / $263.42 / $263.42
| Professional | AS | $263.42 | $263.42 | $263.42 |
- 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 |