- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $7,943.28
| Facility | | $1,995.26 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,073.80
| Professional | | $1,258.93 | $2,238.72 | $4,073.80 |
- 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
- $602.56 / $602.56 / $602.56
| Facility | AS | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $5,128.61
| Professional | | $2,884.03 | $3,467.37 | $5,128.61 |
- 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 |