- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,357.54 / $4,014.00 / $7,119.04
| Facility | | $3,357.54 | $4,014.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.71 / $1,636.74 / $3,515.53
| Professional | | $1,028.71 | $1,636.74 | $3,515.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,767.13 / $2,748.81 / $20,063.05
| Facility | | $1,767.13 | $2,748.81 | $20,063.05 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,708.97 / $4,708.97 / $4,708.97
| Facility | AS | $4,708.97 | $4,708.97 | $4,708.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.00 / $2,748.81 / $17,062.77
| Facility | | $2,047.00 | $2,748.81 | $17,062.77 |
- 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 |