- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $6,606.93 / $28,840.32
| Facility | | $1,479.11 | $6,606.93 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,995.26 / $4,168.69
| Professional | | $1,122.02 | $1,995.26 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $7,413.10 / $27,542.29
| Facility | | $1,778.28 | $7,413.10 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | AS | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $5,754.40
| Professional | | $2,398.83 | $2,754.23 | $5,754.40 |
- 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 |