- 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
- $1,950.27 / $3,242.67 / $5,842.37
| Professional | | $1,950.27 | $3,242.67 | $5,842.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,253.10 / $4,922.21 / $10,463.00
| Facility | | $3,253.10 | $4,922.21 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $967.18 / $967.18 / $967.18
| Facility | AS | $967.18 | $967.18 | $967.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,755.59 / $4,700.27 / $6,147.65
| Facility | | $3,755.59 | $4,700.27 | $6,147.65 |
- 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 |