- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,543.56 / $2,538.58 / $5,358.06
| Facility | | $1,543.56 | $2,538.58 | $5,358.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.00 / $4,963.74 / $6,568.62
| Facility | | $1,529.00 | $4,963.74 | $6,568.62 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $125.45 / $125.45 / $125.45
| Facility | AS | $125.45 | $125.45 | $125.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.25 / $1,387.95 / $1,958.11
| Professional | | $1,040.25 | $1,387.95 | $1,958.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.00 / $2,139.00 / $6,125.00
| Facility | | $1,541.00 | $2,139.00 | $6,125.00 |