- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,370.32 / $7,943.28
| Facility | | $1,258.93 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,621.81 / $4,897.79
| Professional | | $851.14 | $1,621.81 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $7,079.46
| Facility | | $1,513.56 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | AS | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $3,630.78
| Professional | | $1,949.84 | $2,137.96 | $3,630.78 |
- 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 |