- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $4,365.16
| Facility | | $870.96 | $870.96 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,344.23
| Facility | | $1,096.48 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,041.74 / $2,089.30
| Professional | | $1,905.46 | $2,041.74 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $1,862.09
| Professional | | $1,047.13 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | AS | $354.81 | $354.81 | $354.81 |
- 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 |