- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,370.32 / $36,307.81
| Facility | | $1,819.70 | $5,370.32 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,187.76 / $5,248.07
| Professional | | $1,230.27 | $2,187.76 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $8,128.31 / $25,703.96
| Facility | | $1,905.46 | $8,128.31 | $25,703.96 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | AS | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $4,265.80
| Professional | | $2,691.53 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |