- 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
- $2,818.38 / $4,466.84 / $8,511.38
| Facility | | $2,818.38 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $8,128.31 / $8,317.64
| Professional | | $7,585.78 | $8,128.31 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,754.40 / $6,760.83
| Professional | | $4,168.69 | $5,754.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | AS | $1,380.38 | $1,380.38 | $1,380.38 |
- 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 |