- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,365.16 / $7,943.28
| Facility | | $1,148.15 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $3,019.95
| Professional | | $812.83 | $1,230.27 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $31,622.78
| Facility | | $1,288.25 | $2,344.23 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | AS | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,995.26 / $2,398.83
| Professional | | $1,778.28 | $1,995.26 | $2,398.83 |
- 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 |