- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,090.30 / $6,760.83
| Facility | | $794.33 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $2,187.76
| Professional | | $512.86 | $776.25 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,479.11 / $6,025.60
| Facility | | $707.95 | $1,479.11 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | AS | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,513.56
| Professional | | $1,096.48 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,413.10
| Facility | | $3,019.95 | $5,370.32 | $7,413.10 |