- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $7,943.28
| Facility | | $1,737.80 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $4,677.35
| Professional | | $1,202.26 | $2,089.30 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $7,244.36
| Facility | | $1,819.70 | $2,818.38 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | AS | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $3,981.07
| Professional | | $2,630.27 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |