- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,981.07 / $6,760.83
| Facility | | $1,288.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,754.23
| Professional | | $741.31 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,137.96 / $17,782.79
| Facility | | $1,288.25 | $2,137.96 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | AS | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $2,238.72
| Professional | | $1,621.81 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $19,498.45
| Facility | | $5,495.41 | $9,549.93 | $19,498.45 |