- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $6,760.83
| Facility | | $3,235.94 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $6,456.54
| Professional | | $1,778.28 | $3,235.94 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,388.44 / $5,623.41
| Facility | | $1,905.46 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | AS | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,466.84 / $5,248.07
| Professional | | $3,311.31 | $4,466.84 | $5,248.07 |
- 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 |