- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.44 / $1,028.44 / $1,028.44
| Facility | | $1,028.44 | $1,028.44 | $1,028.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.79 / $1,768.15 / $2,702.91
| Facility | | $1,351.79 | $1,768.15 | $2,702.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,561.68 / $2,731.39 / $10,756.16
| Facility | | $1,561.68 | $2,731.39 | $10,756.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.58 / $1,741.53 / $2,048.73
| Professional | | $1,275.58 | $1,741.53 | $2,048.73 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $384.78 / $384.78 / $384.78
| Professional | AS | $384.78 | $384.78 | $384.78 |
- 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 |