- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $959.81 / $959.81 / $3,511.00
| Facility | | $959.81 | $959.81 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.92 / $1,599.23 / $2,537.91
| Facility | | $1,261.92 | $1,599.23 | $2,537.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.92 / $2,376.91 / $8,250.46
| Facility | | $1,461.92 | $2,376.91 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.35 / $1,630.45 / $1,918.06
| Professional | | $1,201.35 | $1,630.45 | $1,918.06 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $360.71 / $360.71 / $360.71
| Professional | AS | $360.71 | $360.71 | $360.71 |
- 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 |