- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,365.16 / $4,897.79
| Facility | | $1,548.82 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $4,168.69
| Facility | | $2,041.74 | $2,630.27 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $3,630.78
| Professional | | $3,388.44 | $3,548.13 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $3,235.94
| Professional | | $1,862.09 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | AS | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |