- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $6,025.60 / $7,943.28
| Facility | | $2,089.30 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $6,918.31
| Professional | | $1,348.96 | $2,137.96 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,890.45 / $17,782.79
| Facility | | $2,089.30 | $3,890.45 | $17,782.79 |
- 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
- $2,951.21 / $3,388.44 / $4,168.69
| Professional | | $2,951.21 | $3,388.44 | $4,168.69 |
- 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 |