- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,370.32 / $7,943.28
| Facility | | $3,235.94 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,311.31 / $7,762.47
| Professional | | $1,995.26 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $7,244.36
| Facility | | $2,951.21 | $5,128.61 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | AS | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,623.41 / $7,244.36
| Professional | | $4,677.35 | $5,623.41 | $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 |