- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $880.68 / $880.68 / $3,073.00
| Facility | | $880.68 | $880.68 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.42 / $1,377.05 / $2,322.10
| Facility | | $1,056.42 | $1,377.05 | $2,322.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,336.58 / $2,009.98 / $2,741.61
| Facility | | $1,336.58 | $2,009.98 | $2,741.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.67 / $1,482.99 / $1,741.45
| Professional | | $1,096.67 | $1,482.99 | $1,741.45 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $327.90 / $327.90 / $327.90
| Professional | AS | $327.90 | $327.90 | $327.90 |
- 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 |