- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $4,365.16
| Facility | | $616.60 | $851.14 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $1,905.46
| Facility | | $870.96 | $1,202.26 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,905.46
| Professional | | $1,380.38 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,621.81
| Professional | | $912.01 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Professional | AS | $316.23 | $316.23 | $316.23 |
- 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 |