- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $4,786.30 / $7,079.46
| Facility | | $1,023.29 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $912.01 / $2,511.89
| Professional | | $549.54 | $912.01 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,659.59 / $17,782.79
| Facility | | $891.25 | $1,659.59 | $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
- $1,230.27 / $1,445.44 / $1,778.28
| Professional | | $1,230.27 | $1,445.44 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |