- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.85 / $720.85 / $3,511.00
| Facility | | $720.85 | $720.85 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.59 / $1,162.08 / $1,952.08
| Facility | | $870.59 | $1,162.08 | $1,952.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.59 / $1,802.85 / $2,824.47
| Facility | | $1,334.59 | $1,802.85 | $2,824.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.62 / $1,252.07 / $1,445.82
| Professional | | $924.62 | $1,252.07 | $1,445.82 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $275.13 / $275.13 / $275.13
| Professional | AS | $275.13 | $275.13 | $275.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |