- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,365.16 / $5,623.41
| Facility | | $1,584.89 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $4,265.80
| Facility | | $2,089.30 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,715.35
| Professional | | $3,467.37 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $3,235.94
| Professional | | $1,905.46 | $2,818.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | AS | $630.96 | $630.96 | $630.96 |
- 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 |