- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,248.07 / $7,943.28
| Facility | | $1,202.26 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $2,398.83
| Professional | | $588.84 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $17,782.79
| Facility | | $1,122.02 | $1,862.09 | $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
- $1,318.26 / $1,621.81 / $2,041.74
| Professional | | $1,318.26 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |