- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $5,370.32 / $7,943.28
| Facility | | $812.83 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,000.00 / $2,238.72
| Professional | | $562.34 | $1,000.00 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,715.35 / $9,772.37
| Facility | | $812.83 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | AS | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $1,659.59
| Professional | | $1,071.52 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,762.47 / $10,715.19
| Facility | | $4,786.30 | $7,762.47 | $10,715.19 |