- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,370.32 / $7,943.28
| Facility | | $1,621.81 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $3,630.78
| Professional | | $1,000.00 | $1,621.81 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $7,244.36
| Facility | | $2,041.74 | $2,818.38 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Facility | AS | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $4,168.69
| Professional | | $2,344.23 | $2,818.38 | $4,168.69 |
- 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 |