- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,248.07 / $7,943.28
| Facility | | $2,511.89 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,238.72 / $4,168.69
| Professional | | $1,445.44 | $2,238.72 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $11,481.54
| Facility | | $2,041.74 | $3,630.78 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | AS | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,630.78 / $4,365.16
| Professional | | $3,162.28 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |