- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,981.07 / $6,760.83
| Facility | | $1,862.09 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $4,570.88
| Professional | | $1,047.13 | $1,862.09 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,089.30 / $6,606.93
| Facility | | $1,096.48 | $2,089.30 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | AS | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,019.95
| Professional | | $1,949.84 | $2,630.27 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,606.93 / $10,232.93
| Facility | | $1,778.28 | $6,606.93 | $10,232.93 |