- 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
- $1,412.92 / $2,309.14 / $3,779.02
| Professional | | $1,412.92 | $2,309.14 | $3,779.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.40 / $3,391.54 / $10,463.00
| Facility | | $2,304.40 | $3,391.54 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $705.44 / $705.44 / $705.44
| Facility | AS | $705.44 | $705.44 | $705.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,653.00 / $3,391.54 / $4,291.97
| Facility | | $2,653.00 | $3,391.54 | $4,291.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,542.00 / $13,657.65 / $16,616.96
| Facility | | $9,542.00 | $13,657.65 | $16,616.96 |