- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $8,912.51
| Facility | | $6,165.95 | $6,165.95 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,884.03
| Professional | | $2,137.96 | $2,137.96 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $11,220.18 / $18,197.01
| Facility | | $6,309.57 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $7,762.47 / $7,762.47
| Facility | | $56.23 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | AS | $776.25 | $776.25 | $776.25 |