- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.91 / $600.91 / $3,511.00
| Facility | | $600.91 | $600.91 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $729.40 / $933.52 / $1,584.11
| Facility | | $729.40 | $933.52 | $1,584.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.47 / $1,495.32 / $2,824.47
| Facility | | $1,039.47 | $1,495.32 | $2,824.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.52 / $1,032.16 / $1,214.23
| Professional | | $623.52 | $1,032.16 | $1,214.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $226.49 / $226.49 / $226.49
| Professional | AS | $226.49 | $226.49 | $226.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $5,724.10
| Facility | | $2,000.00 | $2,000.00 | $5,724.10 |