- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $5,888.44
| Facility | | $1,202.26 | $2,187.76 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $1,862.09
| Facility | | $1,258.93 | $1,479.11 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Facility | AS | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $933.25 / $1,318.26
| Professional | | $707.95 | $933.25 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $3,235.94
| Facility | | $1,023.29 | $1,445.44 | $3,235.94 |