- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.02 / $914.02 / $3,073.00
| Facility | | $914.02 | $914.02 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.88 / $1,464.28 / $2,381.53
| Facility | | $1,114.88 | $1,464.28 | $2,381.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.85 / $2,082.96 / $2,859.45
| Facility | | $1,372.85 | $2,082.96 | $2,859.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.41 / $1,546.13 / $1,851.43
| Professional | | $1,038.41 | $1,546.13 | $1,851.43 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $339.35 / $339.35 / $339.35
| Professional | AS | $339.35 | $339.35 | $339.35 |
- 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 |