- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.53 / $825.53 / $3,511.00
| Facility | | $825.53 | $825.53 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.21 / $1,379.66 / $2,158.19
| Facility | | $1,083.21 | $1,379.66 | $2,158.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.01 / $1,880.72 / $2,575.80
| Facility | | $1,246.01 | $1,880.72 | $2,575.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.15 / $1,391.25 / $1,636.66
| Professional | | $1,021.15 | $1,391.25 | $1,636.66 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $308.08 / $308.08 / $308.08
| Professional | AS | $308.08 | $308.08 | $308.08 |
- 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 |