- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,248.07 / $7,943.28
| Facility | | $2,290.87 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $5,754.40
| Professional | | $1,479.11 | $2,398.83 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,365.16 / $17,782.79
| Facility | | $2,290.87 | $4,365.16 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | AS | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,715.35 / $4,570.88
| Professional | | $3,235.94 | $3,715.35 | $4,570.88 |
- 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 |