- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,025.60 / $7,943.28
| Facility | | $2,290.87 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $3,801.89
| Professional | | $1,318.26 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $14,125.38
| Facility | | $1,949.84 | $3,388.44 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | AS | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $4,073.80
| Professional | | $2,884.03 | $3,388.44 | $4,073.80 |
- 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 |