- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,981.07 / $6,760.83
| Facility | | $851.14 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $2,089.30
| Professional | | $501.19 | $758.58 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,380.38 / $7,079.46
| Facility | | $630.96 | $1,380.38 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | AS | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $1,412.54
| Professional | | $741.31 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $8,912.51
| Facility | | $4,168.69 | $6,309.57 | $8,912.51 |