- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,248.07 / $7,943.28
| Facility | | $1,122.02 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,513.56 / $3,630.78
| Professional | | $851.14 | $1,513.56 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,677.35 / $26,915.35
| Facility | | $1,122.02 | $4,677.35 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | AS | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $4,570.88
| Professional | | $1,737.80 | $2,089.30 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |