- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $7,943.28
| Facility | | $2,951.21 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,951.21 / $5,888.44
| Professional | | $1,659.59 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $5,128.61
| Facility | | $1,778.28 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | AS | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,168.69 / $4,786.30
| Professional | | $3,235.94 | $4,168.69 | $4,786.30 |
- 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 |