- 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
- $1,268.11 / $2,092.27 / $3,645.07
| Professional | | $1,268.11 | $2,092.27 | $3,645.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.58 / $3,037.82 / $10,463.00
| Facility | | $2,106.58 | $3,037.82 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $631.87 / $631.87 / $631.87
| Facility | AS | $631.87 | $631.87 | $631.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,439.64 / $3,037.82 / $3,954.03
| Facility | | $2,439.64 | $3,037.82 | $3,954.03 |
- 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 |