- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,235.94 / $6,760.83
| Facility | | $1,071.52 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $3,162.28
| Professional | | $602.56 | $977.24 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,737.80 / $6,456.54
| Facility | | $1,071.52 | $1,737.80 | $6,456.54 |
- 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
- $1,202.26 / $1,659.59 / $2,041.74
| Professional | | $1,202.26 | $1,659.59 | $2,041.74 |
- 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 |