- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $9,332.54 / $13,489.63
| Facility | | $724.44 | $9,332.54 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,862.09
| Facility | | $912.01 | $1,202.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $1,621.81
| Professional | | $1,479.11 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $1,445.44
| Professional | | $812.83 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Professional | AS | $275.42 | $275.42 | $275.42 |
- 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 |