- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,248.07 / $7,943.28
| Facility | | $2,344.23 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $6,165.95
| Professional | | $1,548.82 | $2,454.71 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,570.88 / $17,782.79
| Facility | | $2,344.23 | $4,570.88 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | AS | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,801.89 / $4,677.35
| Professional | | $3,311.31 | $3,801.89 | $4,677.35 |
- 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 |