- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $11,265.38
| Facility | | $5,012.00 | $6,298.62 | $11,265.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.26 / $2,603.73 / $6,876.15
| Professional | | $1,562.26 | $2,603.73 | $6,876.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.41 / $4,057.81 / $12,871.00
| Facility | | $2,608.41 | $4,057.81 | $12,871.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $765.24 / $765.24 / $765.24
| Facility | AS | $765.24 | $765.24 | $765.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.12 / $3,794.77 / $4,963.29
| Facility | | $3,028.12 | $3,794.77 | $4,963.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,352.00 / $13,970.00 / $16,616.96
| Facility | | $10,352.00 | $13,970.00 | $16,616.96 |