- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,370.32 / $7,943.28
| Facility | | $3,388.44 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $8,511.38
| Professional | | $2,089.30 | $3,388.44 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,248.07 / $7,244.36
| Facility | | $2,951.21 | $5,248.07 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | AS | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,888.44 / $7,762.47
| Professional | | $4,897.79 | $5,888.44 | $7,762.47 |
- 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 |