- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,370.32 / $7,943.28
| Facility | | $2,630.27 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,691.53 / $4,570.88
| Professional | | $1,445.44 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,818.38 / $4,570.88
| Facility | | $1,548.82 | $2,818.38 | $4,570.88 |
- 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
- $2,754.23 / $3,548.13 / $4,265.80
| Professional | | $2,754.23 | $3,548.13 | $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 |