- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,248.07 / $7,943.28
| Facility | | $1,659.59 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,737.80 / $5,011.87
| Professional | | $1,071.52 | $1,737.80 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,162.28 / $17,378.01
| Facility | | $1,659.59 | $3,162.28 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | AS | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $3,235.94
| Professional | | $2,344.23 | $2,630.27 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |