- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,570.88 / $7,079.46
| Facility | | $1,348.96 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,479.11 / $3,388.44
| Professional | | $851.14 | $1,479.11 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,677.35 / $15,848.93
| Facility | | $1,348.96 | $4,677.35 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | AS | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,949.84 / $2,754.23
| Professional | | $1,819.70 | $1,949.84 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $11,481.54 / $15,848.93
| Facility | | $7,943.28 | $11,481.54 | $15,848.93 |