- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.65 / $6,298.62 / $11,265.38
| Facility | | $1,858.65 | $6,298.62 | $11,265.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.08 / $1,132.65 / $2,961.24
| Professional | | $747.08 | $1,132.65 | $2,961.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.98 / $2,146.60 / $23,351.66
| Facility | | $1,103.98 | $2,146.60 | $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
- $1,488.95 / $2,352.50 / $8,854.25
| Facility | | $1,488.95 | $2,352.50 | $8,854.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |