- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $7,762.47 / $10,471.29
| Facility | | $1,412.54 | $7,762.47 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,584.89 / $3,715.35
| Professional | | $891.25 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $7,413.10 / $27,542.29
| Facility | | $1,698.24 | $7,413.10 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | AS | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $3,388.44
| Professional | | $1,949.84 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |