- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,258.73 / $6,960.00 / $21,931.23
| Facility | | $2,258.73 | $6,960.00 | $21,931.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.38 / $1,589.25 / $3,082.19
| Professional | | $909.38 | $1,589.25 | $3,082.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.46 / $2,642.18 / $23,351.66
| Facility | | $1,591.46 | $2,642.18 | $23,351.66 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,632.21 / $2,632.21 / $2,632.21
| Facility | AS | $2,632.21 | $2,632.21 | $2,632.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.00 / $2,941.51 / $8,854.25
| Facility | | $1,673.00 | $2,941.51 | $8,854.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,604.00 / $13,670.06 / $26,737.65
| Facility | | $8,604.00 | $13,670.06 | $26,737.65 |