- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,112.74 / $1,112.74 / $4,338.00
| Facility | | $1,112.74 | $1,112.74 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.21 / $1,885.71 / $3,039.26
| Facility | | $1,459.21 | $1,885.71 | $3,039.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,105.69 / $3,170.10 / $8,250.46
| Facility | | $2,105.69 | $3,170.10 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.90 / $2,032.43 / $2,390.94
| Professional | | $1,478.90 | $2,032.43 | $2,390.94 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $443.46 / $443.46 / $443.46
| Professional | AS | $443.46 | $443.46 | $443.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |