- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,413.12 / $6,602.61 / $11,492.20
| Facility | | $3,413.12 | $6,602.61 | $11,492.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.38 / $1,809.06 / $4,209.37
| Professional | | $1,061.38 | $1,809.06 | $4,209.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.38 / $2,799.02 / $18,644.62
| Facility | | $1,796.38 | $2,799.02 | $18,644.62 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,882.81 / $4,882.81 / $4,882.81
| Facility | AS | $4,882.81 | $4,882.81 | $4,882.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,104.00 / $3,055.06 / $17,366.13
| Facility | | $2,104.00 | $3,055.06 | $17,366.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,352.00 / $13,970.00 / $16,616.96
| Facility | | $10,352.00 | $13,970.00 | $16,616.96 |