- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,370.32 / $7,943.28
| Facility | | $3,090.30 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,951.21 / $6,918.31
| Professional | | $1,905.46 | $2,951.21 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,786.30 / $7,244.36
| Facility | | $2,691.53 | $4,786.30 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Facility | AS | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $5,495.41
| Professional | | $3,467.37 | $4,897.79 | $5,495.41 |
- 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 |