- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,801.89 / $6,760.83
| Facility | | $776.25 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $2,570.40
| Professional | | $501.19 | $831.76 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,479.11 / $15,848.93
| Facility | | $776.25 | $1,479.11 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Facility | AS | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $1,862.09
| Professional | | $1,122.02 | $1,380.38 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |