- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,365.16 / $4,897.79
| Facility | | $1,584.89 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,691.53 / $4,570.88
| Facility | | $2,137.96 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $3,801.89
| Professional | | $3,630.78 | $3,715.35 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $3,388.44
| Professional | | $1,995.26 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | AS | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |