- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,981.07 / $11,481.54
| Facility | | $851.14 | $3,981.07 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $758.58 / $2,290.87
| Professional | | $489.78 | $758.58 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,380.38 / $8,912.51
| Facility | | $776.25 | $1,380.38 | $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
- $1,096.48 / $1,230.27 / $1,479.11
| Professional | | $1,096.48 | $1,230.27 | $1,479.11 |
- 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 |