- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,365.16 / $4,897.79
| Facility | | $1,230.27 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $3,311.31
| Facility | | $1,621.81 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $2,884.03
| Professional | | $2,630.27 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $2,511.89
| Professional | | $1,479.11 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | AS | $478.63 | $478.63 | $478.63 |
- 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 |