- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $5,370.32 / $7,943.28
| Facility | | $933.25 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,174.90 / $2,951.21
| Professional | | $645.65 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,089.30 / $14,791.08
| Facility | | $1,122.02 | $2,089.30 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Facility | AS | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,584.89 / $2,511.89
| Professional | | $1,445.44 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,471.29 / $16,595.87
| Facility | | $7,943.28 | $10,471.29 | $16,595.87 |