- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,897.79 / $7,943.28
| Facility | | $602.56 | $4,897.79 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,905.46
| Professional | | $691.83 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,248.07 / $18,620.87
| Facility | | $912.01 | $5,248.07 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | AS | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $1,862.09
| Professional | | $1,071.52 | $1,348.96 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |