- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,128.61 / $7,943.28
| Facility | | $954.99 | $5,128.61 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $2,454.71
| Professional | | $776.25 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $12,589.25
| Facility | | $1,122.02 | $3,715.35 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | AS | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,089.30
| Professional | | $1,318.26 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,511.38 / $13,182.57
| Facility | | $5,495.41 | $8,511.38 | $13,182.57 |