- 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
- $1,479.76 / $2,360.46 / $3,984.33
| Professional | | $1,479.76 | $2,360.46 | $3,984.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.83 / $3,550.19 / $10,463.00
| Facility | | $2,412.83 | $3,550.19 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $738.44 / $738.44 / $738.44
| Facility | AS | $738.44 | $738.44 | $738.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.86 / $3,550.19 / $4,492.28
| Facility | | $2,780.86 | $3,550.19 | $4,492.28 |
- 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 |