- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,606.93 / $8,128.31
| Facility | | $1,230.27 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $3,388.44
| Professional | | $1,000.00 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,818.38 / $10,232.93
| Facility | | $1,621.81 | $2,818.38 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Facility | AS | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $3,235.94
| Professional | | $2,137.96 | $2,290.87 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,413.10 / $10,964.78
| Facility | | $4,786.30 | $7,413.10 | $10,964.78 |