- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.31 / $2,136.57 / $5,264.70
| Professional | | $1,339.31 | $2,136.57 | $5,264.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,269.69 / $3,671.81 / $26,648.02
| Facility | | $2,269.69 | $3,671.81 | $26,648.02 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $7,686.13 / $7,686.13 / $7,686.13
| Facility | AS | $7,686.13 | $7,686.13 | $7,686.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,640.78 / $3,535.09 / $26,624.83
| Facility | | $2,640.78 | $3,535.09 | $26,624.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,352.00 / $23,366.78 / $47,228.52
| Facility | | $10,352.00 | $23,366.78 | $47,228.52 |