- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.07 / $4,338.00 / $5,545.58
| Facility | | $1,005.07 | $4,338.00 | $5,545.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.90 / $1,635.13 / $2,660.33
| Facility | | $1,216.90 | $1,635.13 | $2,660.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,809.25 / $2,705.18 / $8,250.46
| Facility | | $1,809.25 | $2,705.18 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.09 / $1,697.54 / $1,996.98
| Professional | | $1,254.09 | $1,697.54 | $1,996.98 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $375.64 / $375.64 / $375.64
| Professional | AS | $375.64 | $375.64 | $375.64 |
- 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 |