- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $12,882.50
| Professional | | $3,162.28 | $5,011.87 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,606.93 / $8,912.51
| Facility | | $2,344.23 | $6,606.93 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | AS | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $12,882.50
| Professional | | $5,623.41 | $7,943.28 | $12,882.50 |
- 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 |