- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,370.32 / $7,943.28
| Facility | | $2,344.23 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,754.23 / $5,888.44
| Professional | | $1,584.89 | $2,754.23 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,677.35 / $15,488.17
| Facility | | $2,238.72 | $4,677.35 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | AS | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $4,365.16
| Professional | | $2,754.23 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,471.29 / $16,595.87
| Facility | | $7,943.28 | $10,471.29 | $16,595.87 |