- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,128.61 / $7,943.28
| Facility | | $1,737.80 | $5,128.61 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $5,128.61
| Professional | | $1,096.48 | $1,995.26 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,897.79 / $16,218.10
| Facility | | $1,819.70 | $4,897.79 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | AS | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $3,715.35
| Professional | | $2,041.74 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $17,378.01
| Facility | | $7,413.10 | $10,715.19 | $17,378.01 |