- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $5,011.87 / $7,943.28
| Facility | | $1,230.27 | $5,011.87 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $2,238.72
| Professional | | $691.83 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,041.74 / $17,782.79
| Facility | | $831.76 | $2,041.74 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | AS | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,778.28 / $2,137.96
| Professional | | $1,174.90 | $1,778.28 | $2,137.96 |
- 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 |