- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $7,943.28
| Facility | | $2,137.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $5,623.41
| Professional | | $1,412.54 | $2,238.72 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,890.45 / $14,125.38
| Facility | | $2,137.96 | $3,890.45 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | AS | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,467.37 / $4,265.80
| Professional | | $3,019.95 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $10,471.29 / $16,218.10
| Facility | | $7,244.36 | $10,471.29 | $16,218.10 |