- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.71 / $822.71 / $3,511.00
| Facility | | $822.71 | $822.71 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.27 / $1,353.47 / $2,074.73
| Facility | | $1,075.27 | $1,353.47 | $2,074.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,198.43 / $2,018.04 / $10,477.12
| Facility | | $1,198.43 | $2,018.04 | $10,477.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.12 / $1,350.28 / $1,621.13
| Professional | | $982.12 | $1,350.28 | $1,621.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $296.37 / $296.37 / $296.37
| Professional | AS | $296.37 | $296.37 | $296.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $14,287.46
| Facility | | $3,143.00 | $3,143.00 | $14,287.46 |