- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,370.32 / $7,943.28
| Facility | | $3,630.78 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,162.28 / $7,585.78
| Professional | | $1,862.09 | $3,162.28 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,370.32 / $7,244.36
| Facility | | $1,995.26 | $5,370.32 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | AS | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,754.40 / $6,456.54
| Professional | | $3,801.89 | $5,754.40 | $6,456.54 |
- 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 |