- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,786.30 / $10,964.78
| Facility | | $1,548.82 | $4,786.30 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $4,786.30
| Professional | | $912.01 | $1,380.38 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,630.27 / $17,782.79
| Facility | | $1,318.26 | $2,630.27 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | AS | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,691.53
| Professional | | $1,778.28 | $2,238.72 | $2,691.53 |
- 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 |