- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,910.86 / $5,535.97 / $10,506.16
| Facility | | $1,910.86 | $5,535.97 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.10 / $1,731.12 / $2,892.82
| Professional | | $967.10 | $1,731.12 | $2,892.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.82 / $2,924.41 / $13,268.42
| Facility | | $1,567.82 | $2,924.41 | $13,268.42 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,568.44 / $1,568.44 / $1,568.44
| Facility | AS | $1,568.44 | $1,568.44 | $1,568.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,813.00 / $3,239.76 / $5,659.68
| Facility | | $1,813.00 | $3,239.76 | $5,659.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |