- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,735.39 / $1,735.39 / $17,639.59
| Facility | | $1,735.39 | $1,735.39 | $17,639.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,904.92 / $2,743.33 / $3,941.47
| Facility | | $1,904.92 | $2,743.33 | $3,941.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,414.12 / $4,754.82 / $5,982.74
| Facility | | $3,414.12 | $4,754.82 | $5,982.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,353.92 / $3,305.11 / $3,768.19
| Professional | | $2,353.92 | $3,305.11 | $3,768.19 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $700.45 / $700.45 / $700.45
| Professional | AS | $700.45 | $700.45 | $700.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |