- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,370.32 / $12,589.25
| Facility | | $3,311.31 | $5,370.32 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $6,918.31
| Professional | | $1,819.70 | $3,311.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,311.31 / $5,495.41
| Facility | | $1,949.84 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Facility | AS | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,570.88 / $5,370.32
| Professional | | $3,090.30 | $4,570.88 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |