- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $6,025.60 / $13,489.63
| Facility | | $1,513.56 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $4,570.88
| Professional | | $912.01 | $1,348.96 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $44,668.36
| Facility | | $1,513.56 | $2,570.40 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | AS | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $2,570.40
| Professional | | $2,041.74 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $72,443.60
| Facility | | $8,511.38 | $13,489.63 | $72,443.60 |