- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,370.32 / $7,943.28
| Facility | | $3,715.35 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,570.88 / $10,232.93
| Professional | | $2,630.27 | $4,570.88 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,888.44 / $7,585.78
| Facility | | $2,691.53 | $5,888.44 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | AS | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,165.95 / $8,912.51
| Professional | | $5,888.44 | $6,165.95 | $8,912.51 |
- 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 |