- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $4,265.80 / $16,982.44
| Facility | | $758.58 | $4,265.80 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $3,019.95
| Professional | | $812.83 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $17,782.79
| Facility | | $1,412.54 | $2,398.83 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | AS | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,041.74 / $2,454.71
| Professional | | $1,778.28 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |