- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,463.36 / $16,387.90
| Facility | | $3,496.00 | $5,463.36 | $16,387.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.80 / $1,133.95 / $3,213.72
| Professional | | $657.80 | $1,133.95 | $3,213.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.61 / $1,778.51 / $14,242.22
| Facility | | $1,122.61 | $1,778.51 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,568.08 / $2,568.08 / $2,568.08
| Facility | AS | $2,568.08 | $2,568.08 | $2,568.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.80 / $1,748.23 / $8,748.73
| Facility | | $1,308.80 | $1,748.23 | $8,748.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |