- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,025.60 / $7,943.28
| Facility | | $2,398.83 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $3,981.07
| Professional | | $1,412.54 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,548.13 / $14,125.38
| Facility | | $2,041.74 | $3,548.13 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | AS | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $4,265.80
| Professional | | $3,019.95 | $3,548.13 | $4,265.80 |
- 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 |