- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $4,365.16
| Facility | | $812.83 | $812.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,089.30
| Facility | | $1,000.00 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,819.70 / $1,819.70
| Professional | | $1,698.24 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $1,584.89
| Professional | | $912.01 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | AS | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |