- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $4,365.16 / $7,413.10
| Facility | | $776.25 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $676.08 / $1,659.59
| Professional | | $426.58 | $676.08 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,288.25 / $8,317.64
| Facility | | $676.08 | $1,288.25 | $8,317.64 |
- 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
- $954.99 / $1,096.48 / $1,318.26
| Professional | | $954.99 | $1,096.48 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |