- 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
- $1,380.38 / $1,778.28 / $2,818.38
| Facility | | $1,380.38 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $2,454.71
| Professional | | $2,290.87 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,187.76
| Professional | | $1,258.93 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | AS | $426.58 | $426.58 | $426.58 |
- 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 |