- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,370.32 / $7,943.28
| Facility | | $1,548.82 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $5,623.41
| Professional | | $1,000.00 | $1,621.81 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $6,606.93
| Facility | | $1,380.38 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | AS | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $3,019.95
| Professional | | $2,137.96 | $2,454.71 | $3,019.95 |
- 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 |