- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $4,365.16
| Facility | | $1,380.38 | $1,380.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,995.26 / $3,548.13
| Facility | | $1,778.28 | $1,995.26 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,019.95
| Professional | | $2,951.21 | $2,951.21 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $2,630.27
| Professional | | $1,659.59 | $2,290.87 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | AS | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |