- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $5,011.87 / $7,943.28
| Facility | | $933.25 | $5,011.87 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,949.84
| Professional | | $524.81 | $812.83 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $8,912.51
| Facility | | $891.25 | $1,548.82 | $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
- $1,122.02 / $1,318.26 / $1,584.89
| Professional | | $1,122.02 | $1,318.26 | $1,584.89 |
- 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 |