- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,235.94 / $6,760.83
| Facility | | $1,584.89 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,122.02 / $2,137.96
| Professional | | $645.65 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,630.27 / $7,762.47
| Facility | | $1,348.96 | $2,630.27 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | AS | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $2,398.83
| Professional | | $1,479.11 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,606.93 / $9,772.37
| Facility | | $3,715.35 | $6,606.93 | $9,772.37 |