- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,981.07 / $6,760.83
| Facility | | $1,122.02 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $933.25 / $1,995.26
| Professional | | $676.08 | $933.25 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,862.09 / $8,128.31
| Facility | | $870.96 | $1,862.09 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | AS | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $1,905.46
| Professional | | $1,318.26 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |