- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,981.07 / $6,760.83
| Facility | | $1,348.96 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $3,311.31
| Professional | | $758.58 | $1,202.26 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $17,782.79
| Facility | | $1,348.96 | $2,238.72 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | AS | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,344.23
| Professional | | $1,698.24 | $1,905.46 | $2,344.23 |
- 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 |