- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,365.16 / $5,623.41
| Facility | | $1,047.13 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $3,019.95
| Facility | | $1,380.38 | $1,778.28 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,454.71 / $2,454.71
| Professional | | $2,344.23 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,187.76
| Professional | | $1,288.25 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | AS | $426.58 | $426.58 | $426.58 |
- 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 |