- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,897.79 / $7,762.47
| Facility | | $851.14 | $4,897.79 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $1,862.09
| Facility | | $812.83 | $1,479.11 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | AS | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $707.95 / $1,000.00
| Professional | | $549.54 | $707.95 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $2,511.89
| Facility | | $724.44 | $1,071.52 | $2,511.89 |