- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $4,365.16
| Facility | | $1,202.26 | $1,202.26 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $3,311.31
| Facility | | $1,584.89 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $2,818.38
| Professional | | $2,570.40 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $2,511.89
| Professional | | $1,479.11 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | AS | $478.63 | $478.63 | $478.63 |
- 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 |