- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,365.16 / $5,623.41
| Facility | | $1,096.48 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,951.21
| Facility | | $1,445.44 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,511.89 / $2,511.89
| Professional | | $2,344.23 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $2,187.76
| Professional | | $1,348.96 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | AS | $426.58 | $426.58 | $426.58 |
- 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 |