- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,623.41 / $42,657.95
| Facility | | $2,818.38 | $5,623.41 | $42,657.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $6,606.93
| Professional | | $1,584.89 | $2,951.21 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,715.35 / $9,772.37
| Facility | | $1,778.28 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | AS | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $4,677.35
| Professional | | $3,019.95 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $8,709.64 / $14,454.40
| Facility | | $3,467.37 | $8,709.64 | $14,454.40 |