- 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
- $3,090.30 / $4,786.30 / $12,302.69
| Professional | | $3,090.30 | $4,786.30 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,606.93 / $8,511.38
| Facility | | $2,344.23 | $6,606.93 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | AS | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,585.78 / $12,302.69
| Professional | | $5,495.41 | $7,585.78 | $12,302.69 |
- 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 |