- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.66 / $948.66 / $4,338.00
| Facility | | $948.66 | $948.66 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,250.42 / $1,675.47 / $2,532.21
| Facility | | $1,250.42 | $1,675.47 | $2,532.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.34 / $2,191.63 / $2,990.85
| Facility | | $1,454.34 | $2,191.63 | $2,990.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.02 / $1,619.92 / $1,897.92
| Professional | | $1,195.02 | $1,619.92 | $1,897.92 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $359.43 / $359.43 / $359.43
| Professional | AS | $359.43 | $359.43 | $359.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |