- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.71 / $807.71 / $807.71
| Facility | | $807.71 | $807.71 | $807.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.24 / $1,331.30 / $2,111.73
| Facility | | $1,027.24 | $1,331.30 | $2,111.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $2,003.34 / $3,711.03
| Facility | | $1,285.00 | $2,003.34 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.41 / $1,364.44 / $1,612.72
| Professional | | $992.41 | $1,364.44 | $1,612.72 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $298.56 / $298.56 / $298.56
| Professional | AS | $298.56 | $298.56 | $298.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |