- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $2,570.40 / $6,760.83
| Facility | | $588.84 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $1,445.44
| Professional | | $354.81 | $524.81 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $977.24 / $8,317.64
| Facility | | $588.84 | $977.24 | $8,317.64 |
- 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
- $794.33 / $891.25 / $1,000.00
| Professional | | $794.33 | $891.25 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |