- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.33 / $837.33 / $4,338.00
| Facility | | $837.33 | $837.33 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.05 / $1,318.25 / $2,412.48
| Facility | | $1,114.05 | $1,318.25 | $2,412.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.80 / $2,287.41 / $2,880.30
| Facility | | $1,392.80 | $2,287.41 | $2,880.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.14 / $1,533.12 / $1,803.56
| Professional | | $1,117.14 | $1,533.12 | $1,803.56 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $336.13 / $336.13 / $336.13
| Professional | AS | $336.13 | $336.13 | $336.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |