- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,370.32 / $7,943.28
| Facility | | $3,890.45 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $8,709.64
| Professional | | $2,398.83 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $7,413.10
| Facility | | $2,951.21 | $6,025.60 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | AS | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,309.57 / $8,128.31
| Professional | | $5,623.41 | $6,309.57 | $8,128.31 |
- 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 |