- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,890.45 / $13,182.57
| Facility | | $1,122.02 | $3,890.45 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $3,019.95
| Facility | | $1,479.11 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $2,511.89
| Professional | | $2,238.72 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $2,187.76
| Professional | | $1,230.27 | $1,819.70 | $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 |