- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $4,365.16
| Facility | | $1,698.24 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $4,897.79
| Facility | | $2,089.30 | $2,454.71 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,073.80 / $4,265.80
| Professional | | $3,981.07 | $4,073.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $3,715.35
| Professional | | $2,187.76 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Professional | AS | $741.31 | $741.31 | $741.31 |
- 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 |