- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $4,365.16 / $6,025.60
| Facility | | $537.03 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,380.38
| Facility | | $645.65 | $891.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,202.26
| Professional | | $1,096.48 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $912.01 / $1,071.52
| Professional | | $660.69 | $912.01 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | AS | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |