- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,243.80 / $1,243.80 / $4,338.00
| Facility | | $1,243.80 | $1,243.80 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.36 / $2,102.02 / $3,310.02
| Facility | | $1,637.36 | $2,102.02 | $3,310.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.42 / $2,859.41 / $3,906.45
| Facility | | $1,899.42 | $2,859.41 | $3,906.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.97 / $2,118.31 / $2,485.39
| Professional | | $1,560.97 | $2,118.31 | $2,485.39 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $468.68 / $468.68 / $468.68
| Professional | AS | $468.68 | $468.68 | $468.68 |
- 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 |