- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,370.32 / $7,943.28
| Facility | | $2,041.74 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $4,466.84
| Professional | | $1,258.93 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $7,244.36
| Facility | | $2,344.23 | $3,311.31 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | AS | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,235.94 / $4,570.88
| Professional | | $2,951.21 | $3,235.94 | $4,570.88 |
- 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 |