- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,248.07 / $13,489.63
| Facility | | $1,862.09 | $5,248.07 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $4,897.79
| Professional | | $1,122.02 | $1,698.24 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,162.28 / $31,622.78
| Facility | | $1,862.09 | $3,162.28 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | AS | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,818.38 / $3,235.94
| Professional | | $2,511.89 | $2,818.38 | $3,235.94 |
- 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 |