- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $8,128.31
| Facility | | $1,445.44 | $4,786.30 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $3,162.28
| Professional | | $851.14 | $1,258.93 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $31,622.78
| Facility | | $1,258.93 | $2,398.83 | $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
- $1,584.89 / $2,089.30 / $2,511.89
| Professional | | $1,584.89 | $2,089.30 | $2,511.89 |
- 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 |