- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,393.78 / $4,393.78 / $4,393.78
| Facility | | $4,393.78 | $4,393.78 | $4,393.78 |
- 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
- $120.64 / $120.64 / $120.64
| Facility | AS | $120.64 | $120.64 | $120.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.65 / $1,342.32 / $1,795.78
| Professional | | $1,061.65 | $1,342.32 | $1,795.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |