- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,365.16 / $6,918.31
| Facility | | $851.14 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,041.74
| Facility | | $1,096.48 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,778.28 / $1,862.09
| Professional | | $1,621.81 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $1,659.59
| Professional | | $870.96 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | AS | $302.00 | $302.00 | $302.00 |
- 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 |