- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,511.89 / $8,709.64
| Facility | | $1,122.02 | $2,511.89 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $15,488.17
| Facility | | $602.56 | $602.56 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,905.46
| Professional | | $1,258.93 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,584.89
| Facility | | $758.58 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $14,791.08 / $22,908.68
| Facility | | $5,370.32 | $14,791.08 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $19,952.62 / $19,952.62
| Facility | | $1,995.26 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | AS | $1,995.26 | $1,995.26 | $1,995.26 |