- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,336.97 / $5,475.14 / $5,475.14
| Facility | | $4,336.97 | $5,475.14 | $5,475.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $629.00 / $2,530.00
| Facility | | $582.00 | $629.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $148.22 / $148.22 / $148.22
| Facility | AS | $148.22 | $148.22 | $148.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.81 / $1,593.21 / $2,298.34
| Professional | | $1,292.81 | $1,593.21 | $2,298.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |