- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,107.08 / $3,107.08 / $6,820.27
| Facility | | $3,107.08 | $3,107.08 | $6,820.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.00 / $1,474.16 / $2,213.00
| Facility | | $525.00 | $1,474.16 | $2,213.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $77.44 / $77.44 / $77.44
| Facility | AS | $77.44 | $77.44 | $77.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.17 / $836.49 / $1,208.06
| Professional | | $681.17 | $836.49 | $1,208.06 |
- 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 |