- 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 / $1,258.93 / $2,454.71
| Facility | | $1,071.52 | $1,258.93 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,041.74 / $2,089.30
| Professional | | $1,949.84 | $2,041.74 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $1,778.28
| Professional | | $1,202.26 | $1,584.89 | $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 |