- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,538.21 / $1,538.21 / $4,338.00
| Facility | | $1,538.21 | $1,538.21 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,023.59 / $2,543.53 / $4,118.07
| Facility | | $2,023.59 | $2,543.53 | $4,118.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,360.23 / $3,549.72 / $4,910.71
| Facility | | $2,360.23 | $3,549.72 | $4,910.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.95 / $2,662.54 / $3,123.88
| Professional | | $1,962.95 | $2,662.54 | $3,123.88 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $590.67 / $590.67 / $590.67
| Professional | AS | $590.67 | $590.67 | $590.67 |
- 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 |