- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.18 / $816.18 / $3,511.00
| Facility | | $816.18 | $816.18 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.94 / $1,379.34 / $2,358.76
| Facility | | $1,086.94 | $1,379.34 | $2,358.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.39 / $2,227.54 / $2,808.36
| Facility | | $1,363.39 | $2,227.54 | $2,808.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.88 / $1,493.53 / $1,756.98
| Professional | | $1,093.88 | $1,493.53 | $1,756.98 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $326.74 / $326.74 / $326.74
| Professional | AS | $326.74 | $326.74 | $326.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |