- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $4,365.16
| Facility | | $1,047.13 | $1,047.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,778.28 / $2,951.21
| Facility | | $1,288.25 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,454.71 / $2,570.40
| Professional | | $2,398.83 | $2,454.71 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $2,290.87
| Professional | | $1,318.26 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | AS | $436.52 | $436.52 | $436.52 |
- 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 |