- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $7,943.28
| Facility | | $1,202.26 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,348.96 / $2,951.21
| Professional | | $741.31 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $7,244.36
| Facility | | $1,548.82 | $2,137.96 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | AS | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,162.28
| Professional | | $1,737.80 | $2,089.30 | $3,162.28 |
- 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 |