- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.45 / $3,102.40 / $7,978.30
| Facility | | $490.45 | $3,102.40 | $7,978.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $629.00 / $2,957.55 / $3,837.49
| Facility | | $629.00 | $2,957.55 | $3,837.49 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $38.74 / $38.74 / $38.74
| Facility | AS | $38.74 | $38.74 | $38.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.04 / $435.86 / $605.16
| Professional | | $341.04 | $435.86 | $605.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.00 / $1,679.00 / $3,590.00
| Facility | | $1,236.00 | $1,679.00 | $3,590.00 |