- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,548.13 / $4,365.16
| Facility | | $724.44 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $1,949.84
| Facility | | $891.25 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $1,659.59
| Professional | | $1,548.82 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,445.44
| Professional | | $912.01 | $1,258.93 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Professional | AS | $281.84 | $281.84 | $281.84 |
- 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 |