- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $4,570.88 / $7,079.46
| Facility | | $977.24 | $4,570.88 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,862.09 / $4,265.80
| Professional | | $1,023.29 | $1,862.09 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,888.44 / $15,135.61
| Facility | | $1,513.56 | $5,888.44 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | AS | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $3,548.13
| Professional | | $2,290.87 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $10,715.19 / $15,488.17
| Facility | | $7,413.10 | $10,715.19 | $15,488.17 |