- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $971.55 / $971.55 / $3,073.00
| Facility | | $971.55 | $971.55 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.51 / $1,638.02 / $2,696.82
| Facility | | $1,176.51 | $1,638.02 | $2,696.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,564.40 / $2,441.91 / $7,260.61
| Facility | | $1,564.40 | $2,441.91 | $7,260.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.96 / $1,708.44 / $1,947.82
| Professional | | $1,251.96 | $1,708.44 | $1,947.82 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $379.24 / $379.24 / $379.24
| Professional | AS | $379.24 | $379.24 | $379.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $12,808.14
| Facility | | $4,500.00 | $4,500.00 | $12,808.14 |