- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.08 / $596.08 / $3,511.00
| Facility | | $596.08 | $596.08 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $779.51 / $1,006.04 / $1,532.81
| Facility | | $779.51 | $1,006.04 | $1,532.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,470.33 / $3,711.03
| Facility | | $1,089.00 | $1,470.33 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.96 / $993.98 / $1,182.53
| Professional | | $722.96 | $993.98 | $1,182.53 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $217.87 / $217.87 / $217.87
| Professional | AS | $217.87 | $217.87 | $217.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |