- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.52 / $1,455.52 / $4,338.00
| Facility | | $1,455.52 | $1,455.52 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,912.22 / $2,403.16 / $3,754.40
| Facility | | $1,912.22 | $2,403.16 | $3,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,161.23 / $3,266.14 / $4,573.87
| Facility | | $2,161.23 | $3,266.14 | $4,573.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.72 / $2,442.78 / $2,889.70
| Professional | | $1,776.72 | $2,442.78 | $2,889.70 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $535.08 / $535.08 / $535.08
| Professional | AS | $535.08 | $535.08 | $535.08 |
- 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 |