- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,370.32 / $7,943.28
| Facility | | $1,288.25 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $4,073.80
| Professional | | $891.25 | $1,548.82 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $7,079.46
| Facility | | $1,288.25 | $2,187.76 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | AS | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,089.30 / $2,884.03
| Professional | | $1,905.46 | $2,089.30 | $2,884.03 |
- 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 |