- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $6,760.83
| Facility | | $1,230.27 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $2,041.74
| Professional | | $724.44 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,041.74 / $17,378.01
| Facility | | $1,023.29 | $2,041.74 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | AS | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $2,089.30
| Professional | | $1,584.89 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |