- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,162.28 / $6,760.83
| Facility | | $691.83 | $3,162.28 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $776.25 / $2,238.72
| Professional | | $436.52 | $776.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $5,370.32 / $10,232.93
| Facility | | $630.96 | $5,370.32 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | AS | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,659.59
| Professional | | $776.25 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $10,964.78
| Facility | | $5,128.61 | $8,128.31 | $10,964.78 |