- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,570.40 / $11,481.54
| Facility | | $912.01 | $2,570.40 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,623.41
| Facility | | $3,890.45 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,778.28
| Professional | | $1,047.13 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,412.54
| Facility | | $724.44 | $912.01 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,748.98 / $18,620.87
| Facility | | $5,011.87 | $11,748.98 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,302.68 / $26,302.68 / $42,657.95
| Facility | | $26,302.68 | $26,302.68 | $42,657.95 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | AS | $2,630.27 | $2,630.27 | $2,630.27 |