- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,365.16 / $5,623.41
| Facility | | $1,698.24 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,884.03 / $4,677.35
| Facility | | $2,238.72 | $2,884.03 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Professional | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,090.30 / $3,548.13
| Professional | | $1,995.26 | $3,090.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | AS | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |