- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,981.07 / $6,760.83
| Facility | | $1,122.02 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $2,511.89
| Professional | | $660.69 | $1,023.29 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,905.46 / $8,912.51
| Facility | | $1,122.02 | $1,905.46 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | AS | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $1,949.84
| Professional | | $1,445.44 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |