- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $4,365.16
| Facility | | $1,445.44 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $4,073.80
| Facility | | $1,949.84 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $3,467.37
| Professional | | $3,235.94 | $3,388.44 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $3,090.30
| Professional | | $1,819.70 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | AS | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |