- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $4,365.16
| Facility | | $912.01 | $912.01 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $2,398.83
| Facility | | $1,071.52 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $2,089.30
| Professional | | $1,949.84 | $1,995.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $1,778.28
| Professional | | $1,096.48 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | AS | $354.81 | $354.81 | $354.81 |
- 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 |