- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $7,943.28
| Facility | | $2,137.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,187.76 / $4,265.80
| Professional | | $1,318.26 | $2,187.76 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $7,244.36
| Facility | | $2,344.23 | $3,388.44 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | AS | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,388.44 / $4,677.35
| Professional | | $3,090.30 | $3,388.44 | $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 |