- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $13,489.63
| Facility | | $2,089.30 | $5,248.07 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $4,570.88
| Professional | | $1,230.27 | $1,819.70 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $10,000.00
| Facility | | $1,621.81 | $2,951.21 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | AS | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $3,630.78
| Professional | | $2,691.53 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |