- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,365.16 / $4,897.79
| Facility | | $1,096.48 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,884.03
| Facility | | $1,445.44 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $2,511.89
| Professional | | $2,290.87 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,187.76
| Professional | | $1,288.25 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Professional | AS | $416.87 | $416.87 | $416.87 |
- 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 |