- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $10,255.42
| Facility | | $5,012.00 | $6,298.62 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.11 / $2,670.94 / $4,452.71
| Professional | | $1,660.11 | $2,670.94 | $4,452.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.65 / $3,947.07 / $10,463.00
| Facility | | $2,274.65 | $3,947.07 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $825.64 / $825.64 / $825.64
| Facility | AS | $825.64 | $825.64 | $825.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,969.41 / $5,164.22
| Facility | | $3,143.00 | $3,969.41 | $5,164.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,542.00 / $12,871.00 / $16,293.00
| Facility | | $9,542.00 | $12,871.00 | $16,293.00 |