- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $976.40 / $976.40 / $4,338.00
| Facility | | $976.40 | $976.40 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.20 / $1,594.14 / $2,381.66
| Facility | | $1,233.20 | $1,594.14 | $2,381.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.29 / $2,139.73 / $3,034.65
| Facility | | $1,374.29 | $2,139.73 | $3,034.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.83 / $1,552.03 / $1,901.89
| Professional | | $1,118.83 | $1,552.03 | $1,901.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $343.21 / $343.21 / $343.21
| Professional | AS | $343.21 | $343.21 | $343.21 |
- 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 |