- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.54 / $1,030.54 / $7,191.54
| Facility | | $1,030.54 | $1,030.54 | $7,191.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.16 / $1,769.14 / $3,004.51
| Facility | | $1,377.16 | $1,769.14 | $3,004.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.22 / $3,073.18 / $8,250.46
| Facility | | $1,947.22 | $3,073.18 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.69 / $1,914.41 / $2,182.64
| Professional | | $1,433.69 | $1,914.41 | $2,182.64 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $433.55 / $433.55 / $433.55
| Professional | AS | $433.55 | $433.55 | $433.55 |
- 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 |