- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,370.32 / $7,943.28
| Facility | | $2,344.23 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,388.44 / $6,025.60
| Professional | | $1,905.46 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,025.60 / $10,964.78
| Facility | | $2,238.72 | $6,025.60 | $10,964.78 |
- 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
- $3,388.44 / $4,265.80 / $7,079.46
| Professional | | $3,388.44 | $4,265.80 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,413.10 / $10,964.78
| Facility | | $4,786.30 | $7,413.10 | $10,964.78 |