- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,981.07 / $7,943.28
| Facility | | $1,148.15 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $2,290.87
| Professional | | $645.65 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,905.46 / $17,782.79
| Facility | | $1,000.00 | $1,905.46 | $17,782.79 |
- 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
- $1,412.54 / $1,621.81 / $1,949.84
| Professional | | $1,412.54 | $1,621.81 | $1,949.84 |
- 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 |