- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,025.60 / $7,943.28
| Facility | | $3,235.94 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $5,888.44
| Professional | | $1,949.84 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,677.35 / $14,125.38
| Facility | | $2,754.23 | $4,677.35 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | AS | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,897.79 / $5,754.40
| Professional | | $4,365.16 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $46,773.51
| Facility | | $10,471.29 | $16,218.10 | $46,773.51 |