- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.66 / $1,220.66 / $4,338.00
| Facility | | $1,220.66 | $1,220.66 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.37 / $2,062.92 / $3,413.09
| Facility | | $1,484.37 | $2,062.92 | $3,413.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,933.84 / $3,115.05 / $4,036.82
| Facility | | $1,933.84 | $3,115.05 | $4,036.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.46 / $2,238.96 / $2,552.67
| Professional | | $1,652.46 | $2,238.96 | $2,552.67 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $491.72 / $491.72 / $491.72
| Professional | AS | $491.72 | $491.72 | $491.72 |
- 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 |