- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.90 / $6,304.77 / $7,762.54
| Facility | | $657.90 | $6,304.77 | $7,762.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.54 / $1,772.93 / $2,985.38
| Facility | | $654.54 | $1,772.93 | $2,985.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $64.65 / $64.65 / $64.65
| Facility | AS | $64.65 | $64.65 | $64.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.52 / $731.82 / $1,013.81
| Professional | | $570.52 | $731.82 | $1,013.81 |
- 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 |