- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,370.32 / $7,943.28
| Facility | | $2,570.40 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $7,244.36
| Professional | | $1,778.28 | $3,162.28 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,265.80 / $7,079.46
| Facility | | $2,344.23 | $4,265.80 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Facility | AS | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,265.80 / $6,165.95
| Professional | | $4,073.80 | $4,265.80 | $6,165.95 |
- 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 |