- 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
- $1,562.70 / $2,522.06 / $4,387.71
| Professional | | $1,562.70 | $2,522.06 | $4,387.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.15 / $3,734.33 / $10,463.00
| Facility | | $2,561.15 | $3,734.33 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $776.74 / $776.74 / $776.74
| Facility | AS | $776.74 | $776.74 | $776.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,972.19 / $3,734.33 / $4,822.49
| Facility | | $2,972.19 | $3,734.33 | $4,822.49 |
- 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 |