- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $4,365.16
| Facility | | $776.25 | $776.25 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $2,089.30
| Facility | | $933.25 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,737.80 / $1,778.28
| Professional | | $1,659.59 | $1,737.80 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,548.82
| Professional | | $1,023.29 | $1,380.38 | $1,548.82 |
- 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
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |