- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,466.84 / $7,244.36
| Facility | | $977.24 | $4,466.84 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,096.48 / $2,187.76
| Professional | | $602.56 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $7,762.47 / $14,791.08
| Facility | | $1,202.26 | $7,762.47 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | AS | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $2,511.89
| Professional | | $1,412.54 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $15,135.61
| Facility | | $7,244.36 | $11,481.54 | $15,135.61 |