- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,943.28
| Facility | | $3,162.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $10,715.19
| Professional | | $1,819.70 | $3,311.31 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $5,495.41
| Facility | | $1,905.46 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | AS | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $5,248.07
| Professional | | $3,311.31 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |