- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $7,943.28
| Facility | | $1,023.29 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $912.01 / $2,754.23
| Professional | | $602.56 | $912.01 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,737.80 / $17,782.79
| Facility | | $1,023.29 | $1,737.80 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | AS | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,737.80
| Professional | | $1,318.26 | $1,513.56 | $1,737.80 |
- 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 |