- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,981.07 / $6,760.83
| Facility | | $933.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $851.14 / $2,818.38
| Professional | | $537.03 | $851.14 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $9,772.37
| Facility | | $933.25 | $1,584.89 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | AS | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $1,621.81
| Professional | | $1,202.26 | $1,380.38 | $1,621.81 |
- 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 |