- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $737.53 / $737.53 / $3,511.00
| Facility | | $737.53 | $737.53 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.08 / $1,185.32 / $1,961.60
| Facility | | $897.08 | $1,185.32 | $1,961.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.13 / $1,841.45 / $2,824.47
| Facility | | $1,373.13 | $1,841.45 | $2,824.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.06 / $1,265.86 / $1,489.16
| Professional | | $931.06 | $1,265.86 | $1,489.16 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $279.64 / $279.64 / $279.64
| Professional | AS | $279.64 | $279.64 | $279.64 |
- 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 |