- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,370.32 / $7,943.28
| Facility | | $4,073.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $8,709.64
| Professional | | $2,511.89 | $3,981.07 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,165.95 / $7,762.47
| Facility | | $2,951.21 | $6,165.95 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | AS | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,456.54 / $7,244.36
| Professional | | $4,265.80 | $6,456.54 | $7,244.36 |
- 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 |