- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.60 / $2,209.44 / $4,071.04
| Facility | | $1,215.60 | $2,209.44 | $4,071.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $929.72 / $1,474.16 / $2,476.59
| Facility | | $929.72 | $1,474.16 | $2,476.59 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $92.27 / $92.27 / $92.27
| Facility | AS | $92.27 | $92.27 | $92.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.80 / $994.72 / $1,416.21
| Professional | | $812.80 | $994.72 | $1,416.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.00 / $1,347.00 / $3,219.00
| Facility | | $1,028.00 | $1,347.00 | $3,219.00 |