- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,981.07 / $7,943.28
| Facility | | $1,318.26 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,445.44 / $4,466.84
| Professional | | $812.83 | $1,445.44 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $12,022.64 / $53,703.18
| Facility | | $1,513.56 | $12,022.64 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | AS | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $2,691.53
| Professional | | $1,778.28 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $19,054.61 / $54,954.09
| Facility | | $9,772.37 | $19,054.61 | $54,954.09 |