- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $7,943.28
| Facility | | $1,737.80 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $4,570.88
| Professional | | $1,023.29 | $1,584.89 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,511.89 / $9,772.37
| Facility | | $1,479.11 | $2,511.89 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | AS | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,511.89 / $2,951.21
| Professional | | $2,238.72 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |