- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.16 / $5,696.66 / $10,427.33
| Facility | | $1,278.16 | $5,696.66 | $10,427.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,136.00 / $3,018.07 / $4,939.00
| Facility | | $1,136.00 | $3,018.07 | $4,939.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $118.93 / $118.93 / $118.93
| Facility | AS | $118.93 | $118.93 | $118.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.58 / $1,322.63 / $1,850.46
| Professional | | $1,045.58 | $1,322.63 | $1,850.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.00 / $1,679.00 / $3,590.00
| Facility | | $1,236.00 | $1,679.00 | $3,590.00 |