- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $4,365.16
| Facility | | $1,318.26 | $1,318.26 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $3,630.78
| Facility | | $1,698.24 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $2,951.21
| Professional | | $2,691.53 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $2,570.40
| Professional | | $1,479.11 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | AS | $501.19 | $501.19 | $501.19 |
- 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 |