- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $4,365.16
| Facility | | $794.33 | $794.33 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $1,995.26
| Facility | | $1,047.13 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,778.28
| Professional | | $1,659.59 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $1,479.11
| Professional | | $977.24 | $1,348.96 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | AS | $302.00 | $302.00 | $302.00 |
- 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 |