- 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
- $1,174.90 / $2,137.96 / $4,677.35
| Professional | | $1,174.90 | $2,137.96 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $3,715.35
| Facility | | $1,258.93 | $2,187.76 | $3,715.35 |
- 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
- $1,995.26 / $2,951.21 / $3,467.37
| Professional | | $1,995.26 | $2,951.21 | $3,467.37 |
- 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 |