- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,370.32 / $7,943.28
| Facility | | $1,659.59 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,819.70 / $3,630.78
| Professional | | $1,023.29 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $7,244.36
| Facility | | $1,949.84 | $2,818.38 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | AS | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $3,890.45
| Professional | | $2,398.83 | $2,630.27 | $3,890.45 |
- 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 |