- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,248.07 / $7,943.28
| Facility | | $1,862.09 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $4,168.69
| Professional | | $1,122.02 | $1,698.24 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $11,220.18
| Facility | | $1,513.56 | $2,630.27 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | AS | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $3,235.94
| Professional | | $2,398.83 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $34,673.69
| Facility | | $8,511.38 | $13,489.63 | $34,673.69 |