- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,981.07 / $6,760.83
| Facility | | $1,174.90 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,023.29 / $2,454.71
| Professional | | $660.69 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $17,782.79
| Facility | | $891.25 | $1,905.46 | $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
- $1,412.54 / $1,698.24 / $2,041.74
| Professional | | $1,412.54 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |