- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $4,365.16
| Facility | | $3,090.30 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,168.69 / $7,943.28
| Facility | | $2,187.76 | $4,168.69 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,918.31
| Professional | | $6,606.93 | $6,606.93 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,128.61 / $5,888.44
| Professional | | $3,715.35 | $5,128.61 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | AS | $1,174.90 | $1,174.90 | $1,174.90 |
- 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 |