- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,370.32 / $7,943.28
| Facility | | $1,148.15 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,548.82 / $4,570.88
| Professional | | $776.25 | $1,548.82 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $7,079.46
| Facility | | $1,380.38 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | AS | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $3,311.31
| Professional | | $1,778.28 | $1,949.84 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |