- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,235.94 / $4,365.16
| Facility | | $758.58 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,949.84
| Facility | | $912.01 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $1,698.24
| Professional | | $1,548.82 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $1,479.11
| Professional | | $831.76 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Professional | AS | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |