- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,235.94 / $6,760.83
| Facility | | $1,122.02 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,122.02 / $3,630.78
| Professional | | $707.95 | $1,122.02 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,905.46 / $6,025.60
| Facility | | $1,122.02 | $1,905.46 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | AS | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $2,137.96
| Professional | | $1,445.44 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |