- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $7,943.28
| Facility | | $2,187.76 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,187.76 / $4,570.88
| Professional | | $1,230.27 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $4,677.35
| Facility | | $1,318.26 | $2,398.83 | $4,677.35 |
- 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
- $2,344.23 / $3,019.95 / $3,548.13
| Professional | | $2,344.23 | $3,019.95 | $3,548.13 |
- 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 |