- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,786.30 / $7,079.46
| Facility | | $891.25 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $2,238.72
| Professional | | $537.03 | $812.83 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,513.56 / $8,912.51
| Facility | | $891.25 | $1,513.56 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | AS | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $1,548.82
| Professional | | $1,258.93 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |