- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,025.60 / $7,943.28
| Facility | | $2,238.72 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $3,548.13
| Professional | | $1,288.25 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,951.21 / $9,772.37
| Facility | | $1,445.44 | $2,951.21 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | AS | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $3,981.07
| Professional | | $2,754.23 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $34,673.69
| Facility | | $8,511.38 | $13,489.63 | $34,673.69 |