- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,370.32 / $7,943.28
| Facility | | $2,398.83 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $7,762.47
| Professional | | $1,621.81 | $2,511.89 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $13,489.63
| Facility | | $2,398.83 | $4,168.69 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | AS | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $4,786.30
| Professional | | $3,467.37 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,120.11 / $14,791.08
| Facility | | $7,244.36 | $9,120.11 | $14,791.08 |