- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,370.32 / $13,489.63
| Facility | | $2,630.27 | $5,370.32 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,630.27 / $5,128.61
| Professional | | $1,479.11 | $2,630.27 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,818.38 / $4,677.35
| Facility | | $1,584.89 | $2,818.38 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | AS | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,630.78 / $4,265.80
| Professional | | $2,818.38 | $3,630.78 | $4,265.80 |
- 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 |