- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,548.13 / $4,365.16
| Facility | | $794.33 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $2,238.72
| Facility | | $1,047.13 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $1,819.70
| Professional | | $1,659.59 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $1,584.89
| Professional | | $933.25 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | AS | $309.03 | $309.03 | $309.03 |
- 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 |