- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,786.30 / $7,079.46
| Facility | | $1,698.24 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $4,265.80
| Professional | | $977.24 | $1,513.56 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $31,622.78
| Facility | | $1,698.24 | $2,884.03 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | AS | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $2,884.03
| Professional | | $2,137.96 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $34,673.69
| Facility | | $8,511.38 | $13,489.63 | $34,673.69 |