- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.23 / $5,089.46 / $7,943.37
| Facility | | $2,065.23 | $5,089.46 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.69 / $1,219.22 / $2,646.19
| Professional | | $689.69 | $1,219.22 | $2,646.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,150.27 / $1,935.45 / $14,242.22
| Facility | | $1,150.27 | $1,935.45 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,279.44 / $1,279.44 / $1,279.44
| Facility | AS | $1,279.44 | $1,279.44 | $1,279.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.35 / $1,745.31 / $2,276.50
| Facility | | $1,165.35 | $1,745.31 | $2,276.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |