- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,370.32 / $7,943.28
| Facility | | $2,818.38 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $8,709.64
| Professional | | $1,862.09 | $2,951.21 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,365.16 / $6,606.93
| Facility | | $2,454.71 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | AS | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,677.35 / $5,754.40
| Professional | | $4,073.80 | $4,677.35 | $5,754.40 |
- 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 |