- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,370.32 / $7,943.28
| Facility | | $3,548.13 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,548.13 / $7,762.47
| Professional | | $2,187.76 | $3,548.13 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,495.41 / $7,244.36
| Facility | | $2,951.21 | $5,495.41 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | AS | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,754.40 / $7,079.46
| Professional | | $5,248.07 | $5,754.40 | $7,079.46 |
- 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 |