- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,584.89
| Facility | | $575.44 | $602.56 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Facility | AS | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,412.54
| Professional | | $758.58 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $3,235.94
| Facility | | $1,023.29 | $1,445.44 | $3,235.94 |