- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,370.32 / $7,943.28
| Facility | | $1,348.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $3,890.45
| Professional | | $870.96 | $1,380.38 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $3,548.13
| Facility | | $1,202.26 | $1,949.84 | $3,548.13 |
- 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
- $1,862.09 / $2,137.96 / $3,890.45
| Professional | | $1,862.09 | $2,137.96 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |