- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,760.83 / $11,481.54
| Facility | | $1,230.27 | $6,760.83 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $5,754.40
| Professional | | $1,288.25 | $2,290.87 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,888.44 / $15,135.61
| Facility | | $1,819.70 | $5,888.44 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | AS | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,365.16
| Professional | | $2,884.03 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,488.17
| Facility | | $7,413.10 | $10,715.19 | $15,488.17 |