- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,981.07 / $6,760.83
| Facility | | $776.25 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $707.95 / $1,778.28
| Professional | | $446.68 | $707.95 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,318.26 / $8,912.51
| Facility | | $741.31 | $1,318.26 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | AS | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,348.96
| Professional | | $1,000.00 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,585.78 / $10,232.93
| Facility | | $4,786.30 | $7,585.78 | $10,232.93 |