- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $4,365.16
| Facility | | $933.25 | $933.25 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $2,511.89
| Facility | | $1,096.48 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,089.30 / $2,137.96
| Professional | | $1,995.26 | $2,089.30 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $1,862.09
| Professional | | $1,148.15 | $1,621.81 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | AS | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |