- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $13,182.57
| Facility | | $977.24 | $977.24 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,754.23
| Facility | | $1,174.90 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $2,238.72
| Professional | | $2,089.30 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $1,949.84
| Professional | | $1,230.27 | $1,698.24 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | AS | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |