- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $7,943.28
| Facility | | $1,737.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,949.84 / $4,365.16
| Professional | | $1,174.90 | $1,949.84 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,754.23 / $7,079.46
| Facility | | $1,621.81 | $2,754.23 | $7,079.46 |
- 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
- $2,570.40 / $2,754.23 / $3,890.45
| Professional | | $2,570.40 | $2,754.23 | $3,890.45 |
- 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 |