- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.69 / $769.69 / $3,073.00
| Facility | | $769.69 | $769.69 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.25 / $1,300.78 / $2,269.90
| Facility | | $812.25 | $1,300.78 | $2,269.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.06 / $2,016.46 / $3,285.23
| Facility | | $1,228.06 | $2,016.46 | $3,285.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.76 / $1,367.60 / $1,608.84
| Professional | | $1,007.76 | $1,367.60 | $1,608.84 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $302.55 / $302.55 / $302.55
| Professional | AS | $302.55 | $302.55 | $302.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |