- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,370.32 / $7,943.28
| Facility | | $1,318.26 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,548.82 / $3,715.35
| Professional | | $851.14 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $7,079.46
| Facility | | $1,148.15 | $2,137.96 | $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
- $1,778.28 / $2,089.30 / $3,467.37
| Professional | | $1,778.28 | $2,089.30 | $3,467.37 |
- 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 |