- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,801.89 / $7,413.10
| Facility | | $1,047.13 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $2,884.03
| Professional | | $602.56 | $933.25 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $8,912.51
| Facility | | $1,047.13 | $1,737.80 | $8,912.51 |
- 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
- $1,318.26 / $1,513.56 / $1,778.28
| Professional | | $1,318.26 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |