- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $4,786.30 / $7,079.46
| Facility | | $1,174.90 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $2,818.38
| Professional | | $691.83 | $1,047.13 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,995.26 / $17,782.79
| Facility | | $1,047.13 | $1,995.26 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | AS | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $2,041.74
| Professional | | $1,513.56 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |