- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,370.32 / $7,943.28
| Facility | | $1,698.24 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $3,388.44
| Professional | | $977.24 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $3,388.44
| Facility | | $1,047.13 | $1,862.09 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Facility | AS | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $2,818.38
| Professional | | $1,819.70 | $2,344.23 | $2,818.38 |
- 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 |