- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,786.30 / $7,943.28
| Facility | | $1,230.27 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $2,511.89
| Professional | | $741.31 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,041.74 / $31,622.78
| Facility | | $1,122.02 | $2,041.74 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | AS | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $2,089.30
| Professional | | $1,621.81 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $34,673.69
| Facility | | $8,511.38 | $13,489.63 | $34,673.69 |