- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,370.32 / $7,943.28
| Facility | | $1,819.70 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $3,890.45
| Professional | | $1,122.02 | $1,819.70 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $7,244.36
| Facility | | $2,137.96 | $3,090.30 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | AS | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,677.35
| Professional | | $2,630.27 | $3,162.28 | $4,677.35 |
- 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 |