- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,235.94 / $6,760.83
| Facility | | $1,412.54 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $5,248.07
| Professional | | $933.25 | $1,380.38 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $15,848.93
| Facility | | $1,288.25 | $2,630.27 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | AS | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $2,691.53
| Professional | | $1,905.46 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,748.98 / $23,442.29
| Facility | | $7,413.10 | $11,748.98 | $23,442.29 |