- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $4,365.16
| Facility | | $575.44 | $575.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $1,548.82
| Facility | | $741.31 | $977.24 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,288.25 / $1,288.25
| Professional | | $1,174.90 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $954.99 / $1,122.02
| Professional | | $630.96 | $954.99 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $213.80 / $213.80 / $213.80
| Professional | AS | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |