- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.71 / $4,704.00 / $9,073.02
| Facility | | $2,637.71 | $4,704.00 | $9,073.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.26 / $1,298.69 / $2,907.76
| Professional | | $815.26 | $1,298.69 | $2,907.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,388.27 / $2,164.58 / $20,063.05
| Facility | | $1,388.27 | $2,164.58 | $20,063.05 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,657.58 / $4,657.58 / $4,657.58
| Facility | AS | $4,657.58 | $4,657.58 | $4,657.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,619.72 / $2,164.58 / $16,488.95
| Facility | | $1,619.72 | $2,164.58 | $16,488.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |