- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,370.32 / $7,943.28
| Facility | | $912.01 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $851.14 / $2,187.76
| Professional | | $549.54 | $851.14 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,348.96 / $9,772.37
| Facility | | $776.25 | $1,348.96 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Facility | AS | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $1,584.89
| Professional | | $1,288.25 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $9,120.11 / $14,125.38
| Facility | | $5,128.61 | $9,120.11 | $14,125.38 |