- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $6,025.60 / $7,943.28
| Facility | | $2,754.23 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $4,466.84
| Professional | | $1,659.59 | $2,570.40 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $14,125.38
| Facility | | $2,290.87 | $3,981.07 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | AS | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $4,897.79
| Professional | | $3,388.44 | $3,981.07 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $34,673.69
| Facility | | $10,471.29 | $16,218.10 | $34,673.69 |