- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,370.32 / $53,703.18
| Facility | | $2,454.71 | $5,370.32 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,754.23 / $4,786.30
| Professional | | $1,513.56 | $2,754.23 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,890.45 / $7,244.36
| Facility | | $2,454.71 | $3,890.45 | $7,244.36 |
- 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
- $3,548.13 / $3,890.45 / $5,888.44
| Professional | | $3,548.13 | $3,890.45 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |