- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,548.13 / $4,365.16
| Facility | | $575.44 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $891.25 / $1,778.28
| Facility | | $524.81 | $891.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,445.44 / $1,548.82
| Professional | | $1,412.54 | $1,445.44 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $1,258.93
| Professional | | $724.44 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Professional | AS | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |